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i APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone f209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) f 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. t Job Address 11,013 North Ham Lane City Lodi Lot Sae PM i X62-8 6 Owner's Name Thomas P. Thompson AddressN Ham Lane Phone Contractor Clark Well, Inc Address 2024 E Charter Way License No. 371560 Phone 462-7676 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION �l SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack: ❑ Tracy Type of Casing Specifications FI Public ❑'Other r ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation ° .Approx. Depth I 1 Eastern Surface Seal Installed by 1 . Trts-1-a 1 1 ed Repair Work Done ❑ Type of Pump �Llb H.P. State Work Done_� Well Destruction ❑ Well Diameter Sealing Material Itop 50') ._. Depth Filler Material Melow 501 a TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION E I DESTRUCTION i I (No septic system,permitted if public sewer is d ; } f available within 200 feet.) Installation will serve: Residence—s Commercial_7Other Number-of living units: C Number of bedrooms �' s t . ' - Water table depth i Character of soil to a depth of 3 Meer 1 ✓ - Ca acity No. Compartments r ' SEPTIC TANK ❑ Type/Mfg P I PKG. TREATMENT PLT. ❑ Method of Disposal 4 Distance t`o nearest:' Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ri'l Depth Size Number SUMPS Ll 1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 6 k I hereby cartifyt t I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ` rules and regul o s of the San Joaquin Local Health'Di'trict. Home owner o lic nsed agens ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe so in such nne as to become subject tow kman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol ng: "I ce fy th t in he pert ce of th ork for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Ca, ia." � The applica t al ns t n le drawing on reverse side. 1 Signed X Title: Sec-Tre s Date: 12 Feb 90 FOR DEPARTMENT USE ONLY , 9 r Application Accepted by Date Area 2)' Pit or Grout Inspection by Date Final Inspection b n Date i 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 # 4 FEE AMOUNT DUI: AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. M INFO +.EH 13.24IREV.i/A5) C �3t + EH 1428 o o r