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yy) a v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ f 1601 E. HAZEL T ON AVE., STOCKTON, CA i` Telephone (209) 466-6781 (,rulf PERMIT EXPIRES 'I-YEAR FROM DATE ISSUED ` ; b� �� a�kllyx)p J,� (Complete in Triplicate) ` �� t FU C, ft4 A �. Application is heieby made'to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is r made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. II Job Address 14700 West liSchlte Rd CityTracyLot Size 38 . 35 Acrel r M'n e r Ms I'Energy-.D"evel��"ent'5091- -W Weber=-Ste-1 04a-x: - Owner's Name ress Phone 4-63=34 12f Contractor Clark Well'-.: Address 2024 East Charter License No. 371560 Phone_462-7676 TYPE OF WELL/PUMP: ij NEW WELLXRIX WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE +10 0 t FOUNDATION AGRICULTURE WELL OTHER WELL 75 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ "ridustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 3 f) Dia: of Well Casing 9A'r ❑ Domestic/Private XM gravel Pack }Tracy Type of Casing___2 5 Con duAr: nrSpecifications Steel I'-1 Public Cl Other II CI Delta Depth of Grout Seal 10 ) , Type of Grout_9S ek.,. {ti I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Clark. L 1 Repair Work Done ❑" Type of Pump H.P. State Work Done Well Destruction ❑ Wel! Diameter Sealing Material (top 50'1 r Depth jM Filler Material Welow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIRIADDITION t I DESTRUCTION i I (No septic system permitted if public sewer is 9- ,� __ availahle.witFiin 200 ieet.l Installation will serve: Residence '� Commercial Other _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line h LEACHING LINE ❑ No. & Length of lines � g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth II Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .,t 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 rules and regulations of the San Joaquin Local Health District. 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fotlowing:" ify t i the performance of the work for'which-this.perrnit is issued, I shall employ persons subject to workman's compensa- tion laws o1 C Eifor ' x — .� The applica us IIo a requ in pections. Complete drawing on reverse-side. I Signed Title: VP Clark Well Date: 9 Dec 1988 FOR.DEPARTMENT USE ONLY 9 " �� Application Accepted by Date r Area _a M Pit or Grout Inspection by Date 6; 3d Final Inspection by �14nf�-- Date Additional Comments: 4 t, � O N •' �� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy $35.6385 o"p—�oOyc� l07} cc f Gz/' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 I; I?�-,�aLcCc - �" ?'w -lei FEE f INFO MOUNT DUE AMOUNT REMITTED �K H RECEIVED BY DATE PERMIT"NO. t-� + EH 13-24(REV.t i is 51 /D r7�S',� �' G / r V V EH 14-28 ! V v Q Vh r 4