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APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '4 YEAR FROM DATE ISSUED a (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 7076 HWY. 12,L0di,Ca. city Lodi Lot Sire 28acres PM Owner's Name Leonard Thompson Address 21030 N. Davis Rd.Lodi,Ca. Phone 369.20 60 Galt,Ca.95632 Contractor Woods Well Dril�lAddress 11944 Simmerhoyrn Rdtit:ense No. 282866 Phone_ 745-2407 TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ —DISTANCE TO-NEAAEST: SEPTIC TANK --i SEWER LINES"_ ' DISPOSAL FLD. -150 4PROP.•LINE- .40 FOUNDATION1.5ri7— AGRICULTURE WELL OTHER WELL 8()1 PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS &tt ❑ Industrial IV Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Steel t Specifications 12 ga. Q D Public Cl Other ❑ Delta Depth of Grout Seal 00 Type of Grout Sands Cemd6t I I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by Woods Repair Work Done ❑ Type of Pump Submerslb.$e 1hp State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_' Other d t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal f�J Distance to nearest: Well Foundation Property Line ti LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS _ 11 Depth Size Number SUMPS— L-I 'Distance to nearest: `'` Well Foundation '' ' Property'Line._. DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. EHome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f r all r uired inspections. Complete drawing on reverse side. 0 Signed X Title: Contractor Date� �/8$ ,t kOR DEPARTMENT USE ONLY f.x ,t!.a "?4L } Application Accepted by r' Date �f Area f a j � A Date E Pit or Grout Inspection by Date Final Inspection b t Additional Comments: C � ❑ 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 FEEAMOUNT DUE AMOUNT REMITTIED CK CASH RECEIVED BY DATE PERMIT-NO. INFO ryt�,{ ♦ EH13-24MEV.1/H 51 116-, 'e -.�'►' II V(J pp ��1p7 EH 14-26 i ��