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"WWI APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CAqI At1 G 8 IS, Telephone (209) 466-6781 SAN JOAQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH SEPVS;;�' , (Complete in Triplicate) ENVIf40,N`ENTAL HEALTH Diar:; r 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 - 225 South Cherokee Lane City Lodi Lot Size PM Owner's Name ARCO Products Company Address P.O. Box 5811, San Mateo, CA Phone -2434 Contractor Woodward Dri11ing Co. Addres,P.0. Box 336, Rio ViStaCAic9n eNo. (C-57)58163Phone 374-4 00 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CX Vapor Well DISTANCE TO NEAREST: SEPTIC TANK ;>50ft SEWER LINES >50ft DISPOSAL`FLD. NA PROP. LINE nla FOUNDATION —1—Oft AGRICULTURE WELL NA OTHER WELL 30ft PITS/SUMPS _NA_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 U11 Dia. of Well Casing Orr ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications F1 Public ❑ Other Ll Delta Depth of Grout Seal at 1 east 1 Oft Type of Grou 1 to I I Irrigation 55--Approx. Depth I I Eastern Surface Seal Installed by nrl 1 l pr _ Repair Work Done ❑ Type of Pump Maximum H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 X Remediation Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t (� Number of living units: Number of bedrooms V ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK L1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to 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 SUMPS L1 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. 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 call for al equired ' spections. Complete drawing on reverse side. Signed x Title: Project Geologist Date: 8-1-91 Eloise K. Fri c FOR DEPARTMENT USE ONLY Application Accepted by t _ i4 Area �� Pit or Grout Inspection by Date so42 1111 Date Additional Comments: ` 14 1 ❑ 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 95201FEE CK INFO AMOUNT DUE AMOUNT REMITTED /ryC�'ASH EC IVED 8Y DATE PERMITNOO.. a.EH t3-24(REV. i H 5)�� `sem/,r/l,/ Y• / ,'W7 8 A1 EH 14-26 V