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APPLICATION FOR PERMIT 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 fieieby 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 Tr3C� Lot Size PM --- Owner's Name Thermal F-ne gy --,Address 14800 W. Schulte Rd _ Phono --836-2449 534198 836-2949 Tracy Constructors Address 14800 W. Schulte Rd License No.__ _Phone Contractor - TYPE OF WELL/PUMP: NEW WELL 171 WELL REPLACEMENT ❑ DESTRUCTION _J 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 1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Giout s _ I �* I I Irrigation i,Approx. Depth I I Eastern Surface Seal Installed by. \ Repair Work Done ❑ Type of Pump H,P. State Work Done E Well Destruction ❑ Well Diameter _ Sealing Material Itop 501 - — y Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION�Cl REPAIR/ADDITION 1 i DESTRUCTION I 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 _ 132' Character of soil to a depth of 3 feet: Sandy_Clav _ - _-Water table depth SEPTIC TANK L7 Type/Mfg __-.. Capacity f '�� _ -__e' No. Compartments - 2 _. PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING /_INE. ❑ No. & Length of lines ... 34 _:_ Total length/size 368/4"0 i FILTER BED ❑ Distance to nearest: Well 300 Foundation 50 Property Line- BOO t SEEPAGE PIT I I Depth __ 7 Size- _ 54?X Number. ..� SUMPSIL; S i 1 Distance to nearest: Well 70O Foundation -- Property Line 200 DISPOSAL PONDS ❑ 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 EAtrict. 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 following:"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." I The applicant must for all required i ctions. Complete drawing on rave side. Signed X----- /� Y Title: Dater. .... FOR DEPARTMENT USE ONLY � Application Accepted by /r,"j� x. — Dr/- ate � 7 Area Pit or Grout Inspection by Date Final Inspection by 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 REMITTEDC K H RECEIVED BY DATE PERMIT-NO. INFO _ ..EH 13-26 iR�l. D_U0 —70•oo 333 { EH 14-2tS "�i