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APPLICATION FOR PERMIT v SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ... Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hefeby 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 RdPhone 836-2949 Contractor Tracy Constructors Address 14800 W. Schulte Rd License No. 534198 Phone 836-2949 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public h Other 11 Delta Depth of Grout Seal Type of Grout _ ' I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by- Repair y-Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ M TYPE OF SEPTIC WORK: NEW INSTALLATION IKI REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is Q available within 200 feet.) Installation will serve: Residence_ Commercial X Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Sandy Qla132 t —Water table depth SEPTIC TANK ❑ Type/Mfg +� Capacity '� ' '�� No. Compartments 2 , PKG. TREATMENT PLT. ❑ Method of Disposal �y Distance to nearest: Well Foundation Property Line \I\ LEACHING LINE ❑ No. & Length of lines 34 Total length/size 368/4"0 FILTER BED ❑ Distance to nearest: Well 300 Foundation 50 Property Line 300 SEEPAGE PITS 1 1 Depth Size �7 O r)C.R--0 Number. • SUMPS ' Ll Distance to nearest: Well 700 Foundation -- Property Line 200 DISPOSAL PONDS ❑ 1 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, 1 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 following: "I certify that in the performance of the work for which this permit is issued„1 shall employ persons subject to workman's compensa- tion laws of California.” .. The applicant must for all required i ctions. Complete drawingon rev er side. Signed X_ /? y –'• �f Title: �� Date: FOR DEPARTMENT USE ONLY Application Accepted by !/" y� �i:�%�_� Date ' _Area Pit or Grout Inspection by L Date Final Inspection by Date 7a 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 INFO AMOUNT DUE AMOUNT REMITTED C 14CK H RECEIVED BY DATE PERMIT'NO. A .H t13-28 3-21 IRA i_ 5. p-o V < -70.Qu 33o