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. �C3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 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. Job Address 14800 W. Schulte City Tracy Lot Size PM _ Owner's Name Thermal Energy Address 14800 W. Schulte Rd Phone 836-2949 Trac Constructors 14800 W. Schulte Rd License No. 534198 Phone 836-2949 Contractor Y Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE Tb.-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F Type of Grout �. 1"1 Public f 1 Other ❑ Delta Depth of Grout Seal r� ; I I Irrigation —.Apprax. Depth i I Eastern Surface Seal installed by - \ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 41 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted-if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial X Other �l k Number of living units: Number of bedrooms 132w Character of soil to a depth of 3 feet: Ltd la Water table depth SEPTIC TANK ❑ Type/Mfg �� - Capacity 'f� ^`- No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 34 Total length/size 368/4"0 i FILTER BED ❑ Distance to nearest: Well 300 Foundation 50 Property Line _O0 SEEPAGE PITA l I Depth Size, Number.. SUMPS '`'i �s Ll Distance to nearest: Well 700 Foundation -- Property Line 200 ' DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance withSanJoaquin county ordinances, state laws, and - rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the fallowing: "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 fallowing: "I certify that in the performance of the work for which this permit is issued,,,-I shall employ persons subject to workman's compensa- tion laws of California." The applicant must 0 for all required i ctions. Complete drawing on rover side. Signed X Title: Date: Y FOR DEPARTMENT USE ONLY Application Accepted by / Date Pit or Grout Inspection by Date Final inspection by ll Area Data �� Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I C K H RECEIVED BY DATE PERMIT-NO. INFO r-EH 13-24 iR.F�I.r i 51 O��(� —7D�O U ?30 EH 14-2tS u:_ .