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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZETON AVE., STOCKTON, CA Telephone Q091 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 Sari 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 11013 North Ham Lane city Lodi _ Lot size _ PM - - Owner's Name ThOIT1aS P. Thompson _ Address 11013 N Ham_ Lane -- Phone 462-8363 Contractor Clark Well, Inc Address _20,24 E Charter Way_• License No. 371560 __Phone 462-7676 - --- - TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT C DESTRUCTION C PUMP INSTALLATION X-1 SYSTEM REPAIR n OTHER DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. . PROP. t INE FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial F--. Open Bottom C Manteca Dia. of Well Excavation ` Dia. of Well Casing X Domestic/Private O Gravel Pack ❑ Tracy Type of Casing _ Specifications 1'1 Public -1,Other r F1 Delta Depth of Grout Seal — ._ ,Type of Giout I I Irngation ' ,Approx. Depth I I Eastern �S.rla a Seat Installed by_. - Repair Work Done ❑ Type of Pump q ub H.P. —•- _- — State Work Done _Ins tal 1 P d Well Destruction LJ Well Diameter — Sealing Material flop 501 - — Depth _ Filler Material (Below 601 TYPE OF SEPTIC WORK: NFW INSTALLATION 1. REPAIR/ADDITION I DESTRUCTION I 1 (No septic system permitted if public sewof is d f f available within 200 feet.) Installation will serve: Residence—� Commercial— Other Numberof living units: _.` .. )Number of bedrooms r - Water table depth Character of soil to a depth of 3 feet: - SEPTIC TANK LD i Type/Mfg3 f y-- Capacity_ No. Compartments 1 , : • ) PKG. TREATMENT PLT, Cl t �� Method of Disposal Distance o nearest Well _ Foundation Property Line LEACHING LINE .r, No. 8 Length of lines _ Total length/size— FILTER ength/size FtLTER BED ❑ Distance to nearest: Well_- Foundation Property Line _ f SEEPAGE PITS l Depth _� —Size Number - t SUMPS -''L: Distance to nearest: Weil— Foundation Property Linc DISPOSAL PONDS '] 1 t I hereby certify t �t I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances• state laws, and odes and rag o s of the San Joaquin Local Health District.. Home owner o lic nsed age s gnature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any pe so to such one as to become subject to w kman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol ng: - ce fy t t in he perf a of th orlc for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca ia." -4- - The applica t at ns t n to drawing on reverse side. l Signed X t — Title: —_ Sec—Tres Date: 12 Feb 90 FOR DEPARTMENT USE ONLY J Application Accepted by / — Date'Z_ � Area - .2 Pit or Grout Inspection by Date— Final Inspection b `? Data Additional Comments: _- - f i Stk 466-6781 ❑ Lodi 369-3621 0 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 CASH RECEIVED BY DATE PERMIT NO. INFO J t + EH 1324 IREV.r'HSir EH 14-26