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E� APPLICATION FOR PERMIT �$ SAN JOAQ.UIN LOCAL HEALTH DISTRICT VI(S f 1601 E. HAZEL T Ot A DMSI014 Telephone (20 1 MIT PERMIT EXPIRES 1 YEAR FR4TJ 1d�1'j (Complete in Triplicate} Application is hepeby 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 225 South Cherokee Road City Lodi Lot Size PM Owner's Name Arco Products Company Address P.O. 5$11 San Mateo CA Phone 415-571-243 Contractor Wayne Drilling Address P.O. Box 726, Lincoln, ��ense No. 376345 Phone 916-965-935 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER X)Soil boring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. 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 f'l Public FI Other n Delta Depth of Grout Seal Type of Grout cement-Lbentc nite I 1 Irrigation —.-Approx.Depth I I Eastern Surface Seal Installed by water Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ' C Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is (� available within 200 feet.) 1 Installation will sere: Resilience_ Commercial_ Other-- (' Number of living units: Number of bedrooms o Character of soil to a depth of 3 feet: ateerr table depth SEPTIC TANK ❑ Type/Mfg Capacity ITS PKG. TREATMENT PLT. ❑ � 1 Distance to nearest: Well Foundation ProM7tw inr p LEACHING LINE ❑ No. & Length of lines Total / QUIN COUNTY FILTER BER ❑ Distance to nearest: Well Foundation I LALTH e y CCS SWR I@�� SEEPAGE PITS I I Depth Size Number , SUMPS ❑ 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. I 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 calf for all required inspections. Complete drawing on reverse side. Signed X Title. —Project CPnlogist _ Date: —M;3y 7, 1990 Eloise Frick .FOR DEPARTMENT USE ONLY Application Accepted by _ Date 5 IFAV Area 7— Pit Pit or Grout Inspection by Date Final Inspection by Date 7 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 FEEi INFO AMOUNT DUE AMOUNT REMITTED gs K H RECEIVED BY DATE PERMIT'No. ♦.EH 14-y�EH 13-24[REV.i i n 51 �3ao - 515/q p q O-1 J r