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APPLICATION FOR PERMIT tiv SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 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 17421 Bowser Rd* City Lodi Lot Size SPLCw PM r Owner's Name Bill Davis Address 2417 Iramaa'Ave:Stoekton Phone 941-80-20 Galt Ca 95632 -�- � Contractor Woods Well Drillivaress 11944 Simmethorn Rd ,Cense No. 282866 Phone 745-2407 TYPE OF WELL/PUMP:, NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1504 SEWER LINES 150' DISPOSAL FLD. PROP. LINE AGRICULTURE WELL_ ` OTHER[_WELL"— `E PITS_//SbI PS' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATONS # ❑ Industrial X Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing sit Domestic/Private ❑ Gravel Pack [I Tracy Type of Casing 12e9i Steel Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal 50 Type of Grout 'n"doCP_]>t 1 1 Irrigation _..Approx. Depth I'1 Eastern i Surface Seal Installed by Woo Well Drilling Repair Work Done L] Type of Pump S7 H.P- 2 State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l--1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ 'Other 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 y PKG. TREATMENT PLT. ❑ Method of Disposal i Distance 10 nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number = - SUM(S - —LI- Distance to nearest:- r 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. 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." The applicant.must call for II reed inspec' ns. Complete drawing on reverse side: Signed itle: .Contr ctor Date: 3-25-88 R e DEPA MENT USE ONLY R AYJWE.[�T VED Application Accepted by Datef�r� Arena ' Pit o,toy Grou'Inspection by Data _r: Final Inspection by r R Dat1A I/ �� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385pFpp� HEALTH Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200V &Vrd,� iC'ES FEb INFO ygpAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. ♦ EH13-24(REV.tiH51 EH 14-26 LLL /