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We 1 1 s to;be 1'r2p 16 ce d APPLICATION FOR PERMIT - 4 SA'N JOAQUIN LOCAL HEALTH DISTRICT #88 & #111 s 1601 E. HAZEL T ON AVE., STOCKTON, CA to replace 8: & 1 Red r i 1 1 < Telephone (209) 466-6781 PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED 's II (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 900 S. Cherokee .Lane City Lod i Lot Size I' PM - } Owner's Name Kayo Oi,l Company Address 900 S. Cherokee Lane Lodi CA Phone 29/368-2731 h J. H. Kleinfelder ' 2825 E. Myrtle St. 95240• I� Contractor Address License No�+k 2-,-�5Mcne2097948-1345 TYPE OF WELL/PUMP: NEW WELL, ❑ WELL REPLACEMENT 91 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK NA ' SEWER LINES 55' r DISPOSAL FLD. NA PROP. LINE 10' FOUNDATION 25 t' AGRICULTURE WELL NA OTHER WELL PITS/SUMPS NA INTENDED USE ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ® Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation O Dia. of Well asing 2�r ❑ Domestic/Private Pq Gravel Pack C Tracy Type of Casing PVCSpecifications I'i Public 1-1 Other fl Delta Depth of Grout Seal t0 SUrfaGe Type of Grout Bentonite I I Irrigation 50 r.Approx. Depth [ 1 Eastern Surface Seal Installed by Contractor Cement Repair Work Done ❑ Type of pump none', H,P. State Work Done_ Ip Well Destruction ❑ Well Diameter 211 " Sealing Material (top 501 Bentonite-Cement IM ' Monitoring Well Depth 50' Filler Material IBelnw 50') none-shallow we 1 1 IM TYPE_ OF SEPTIC WORK: NEW INSTALLATION I.i REPAIR/ADDITION i_I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet 1 i Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tabfe depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ . Method of Disposal Distance to nearest: ' Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size p� FILTER BED ❑ Distance to nearest: Well Foundation Property Line i i SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation ,,.y Property Line I DISPOSAL PONDS ❑ I s{ _. IA 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 per lt 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 m st call for all r2SU4ed inspections!Complete drawing on reverse side. , Signed Title: Environmental Engineer Date: June 5, 1987 Q�(�� (� FOR DEPAENTS ONLY {� Application Accepted by \ {�7LtU/�+ !– I Data f Area �P Pit or Grout Inspection by Date Final Inspection by Date Additional Comments'. I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑'Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO NT REMITED AMOUNT DUE AMOUNT RECEIVED BY DATE PEIT'NO. SH RM + EH 14-24 IREV.t i n sl / ��K II 7 EH 14-29