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APPLICATION FOR PERM SAN JOAQUIN LOCAL HEALTH DISTRICT &hLTH ,$ 1601 E. HAZELTOq� � � Telephone (207FR MIT PERMIT EXPIRES TYEA (Complete in Triplicate) i 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 Road City Lodi Lot Size PM Owner's Name Arco Products Company Address P.O. 5811 , San Mateo, CA Phone 415-571-243 Contractor Wayne Drilling Address P.O. Box 726, Lincoln, 94ense No. 376345 Phone 916-965-935 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 10 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 ("1 Public ❑ Other CI Delta Depth of Grout Seal Type of Grout cement/bentc r I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by water _ Repair Work Done ❑ Type of Pump — H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I R[PAIR/ADDITION I I DESTRUCTION I I INo 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— PKG. apacity PKG. TREATMENT PLT.❑ � �� I Distance to nearest: Well Foundation Pro"pffin LEACHING LINE ❑ No. & Length of lines Total j (r WQUIN COUNTY FILTER BED ❑ Distance to nearest: Well Foundation I eEALSERVICES �tavtR �BS�€�i A2 REacTtJ-mrs,ora _ SEEPAGE PITS I I Depth Size _ Number SUMPS Ll 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 ONtrict. _ 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 all required inspections. Complete drawing on reverse side. Signed X "- { y_ Title: PrOPCt QP0109iStDate: May 7, 199(1 Eloise Frick FOR DEPARTMENT USE ONLY Application Accepted b- Date Date — Area K Z' Pit or Grout Inspection by Date Final Inspection by _ Date _ 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 FEE AMOUNT DUE AMOUNT REMITTED K INFO tAtR RECEIVED BY DATE PERMIT NO. f.EH 13.24 IREV.1/"5) y300 ' 5/7 15 _ EH 14-N