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;' ._L� APPLICATION FOR PERMIT 1.1 ✓ d SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 P 19 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNITY (Complete in Triplicate) PUBLIC HCA1 T H SERVI(,ES ENVIR�f��t 9i b4c�l F%i on is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor � �I 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 GL,adv City Lodi Lot Size PM Owner's Name Arco Products Company Address P.O. Box 5811 , San Mateo, CA Phone 415-571-2434 Contractor Wayne Drilling__—Ad dress P 0 Box 726, Lincoln License No. 376345 Phone_916-965-93 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER N Soil boring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 71 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Cem n ritC lte 1 1 Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by wa r - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines %tal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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 Di§trict. 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 mu all f all required inspections. Complete drawing on reverse side. Signed ) �� Title: Project Geologist Data:Septenber '4;, 1990 Eloise Frick OR DEPARTMENT USE ONLY pp /� Application Accepted by Al! }� � Date 7Q4ALr -( ,�_ r_ Pit or Grout Inspection by Date Final Inspection by DateIi9l Additional Comments: O Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO (�/;.. Zvi CASH 9 G� y�C� FH 13-24 EH 14-26(REV.t/A 5) y y�� 9 4/ { i {0