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APPLICATION FOR .PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466_6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 186'2 for well/pump and the Rules and Regulations of the San Joaquin <br /> 1 <br /> Local Health District. 1 <br /> q <br /> Job Address 14700 West SChuZte Rd <br /> City Tracy Lot Size as- pM <br /> Owner's Name Thermal Energy ,501 W. WeberSte 1046 <br /> Address Phone 463-3411 <br /> Contractor's NameClark Well 371 560 <br /> TYPE OF WELL/PUMP: License No. <br /> NEW WELL� C1Phone 4620-7676 <br /> PUMP INSTALLATION ElWELL REPLACEMENT ❑ DESTRUCTION <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> FOUNDATION <br /> SEWER LINES � DISPOSAL FLD. 1 0 Q r PROP. LINE AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> Y,�r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> "ter lndUstrial ❑ Open Bottom ,� <br /> ❑ Manteca Ufa. of Well Excavation 6 5/8 <br /> ❑ Domestic/Private XXN Gravel Pack ��rac Dia. of Wail Casing <br /> ❑ Public ❑ Other y Type of Casing Steel Specifications . 1 9 S t e e <br /> El Depth of Grout Seal 5 <br /> ❑ Irrigation ---Approx. Depth El Eastern Type of Grout Lentonite <br /> Repair Work Done ❑ T Surface Seal Installed by Owner tF <br /> Type of pump H p � <br /> Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Material (top 50') --� <br /> Depth Filler Material (Below 50') Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is O <br /> Installation will serve: ResidenceCommercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity _ No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ElDistance to nearest: Well Total length/size , <br /> Foundation Property Line t <br /> 1 <br /> SEEPAGE PETS ❑ Depth <br /> SUMPS Size <br /> ❑ Distance to nearest: Well ' <br /> DISPOSAL PONDS Foundation Property Line <br /> ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. r <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." P p y persons subject to workman's compensa- <br /> The applicant t all le ed s ti S. Complete drawing on reverse side. <br /> Signed g <br /> Title: VP Clark Well <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by e 1 <br /> Date Q p�rea <br /> —AZ <br /> Pit or rut spection by <br /> Data Final Inspection b <br /> Additional Comments: Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 <br /> FEE AMOUNT DUE CK# <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE <br /> PERMIT"NO. <br /> Eh14 -2266(REV.ioieai I <br /> SIS 7 <br /> T Aa .—_ <br />