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AF`PLICA]'ION f 0R 111 Ht M I I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F HAZE'LTON AVE., STOCK TON, CA 11 12, 13 , 8, I and 1 redr-i 11 Telephone; (209) 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Coiiiplete in Triplicate) Application is heiehy made to the San Joaquin Local Health District for a permit to ccuisnu, .,nd/or install the work herein described. This application is made in compliance with San Joaquin Comity Ordinance No. 549 for sewage or No 1802 f�,r welVpuny,and the Rules and Re13 ilations of the San Joaquin Local Health District Job Address _ 900 S. Cherokee Lane city Lodi - t.otSize - --- - -- -.__ PM ---- Owner's Name Kayo Oil Company Address 900 S. Cherokee Lane, Lod i, CA___ Phone 20 X68-2731 Stockton CA 95240 Contractor J. H. Kleinfelder Address282S E. Myrtle St. , ��r2(C_57a 209/948-134 — --- _ License No. hone_ TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACE Tf i DESTRUCTION X PUMP INSTALLATION ( 1 SYSTEM REPAIR I OTHER I i ! DISTANCE TO NEAREST: SEPTIC TANK _.NA SEWER LINES _-25-'-- - . DISPOSAL FLD.-NA---- PROP. LINE FOUNDATION _25--- AGRICULTURE WELL NA ___ OTHER WELL__LO _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --- - - -- ---- _. X Industrial 1 . Open Bottom + 1 Manteca Dia. of Well Excavation Q } _ Dia. of Well Casing 211 _ I ! Domestic/Private IX Gravel Pack ( 1 Tracy Type of Casing __PUC Specifications Pohlic Other 1 1 Delta Depth of Grout Seal t0_Surface- Type of Grout Benton 11_e— Irngel'on 55 Approx. Depth 1 Eastern Surlace Seal Installed by- Contractor — Cement Repair Work Doer i i Type of Pump none H P _ — State Work Done Well Destruction X Well Diarneter 211 _ Sealing Material (top 50') Benton i te-Cement DepthS1�- Filler Material (Below 50'1 Bentonite-Cement _ TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic systern permr\ed 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 1 1 Type/Mfg _ Capacity No- Compartments PKG TREATMENT PLT I I Method of Disposal Distance to nearest: Well Foundation Property Line I FACHING LINE I I No. & Length of lines _ - Total length/size _ FILTER BED 1 1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth -__ _ Size Number SUMPS I ! Distance to nearest: Well Foundation -__ _- Property Line DISPOSAL PONDS i I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Taws, 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 most call for all required inspections. Complete drawing on reverse side. Signed x _ >r�_ Title: EnVi ronmentaI Engineer Date: June 5, 1987 t 7 >t i -7 t� ,(`�� FOR DEPARTMENT6 �NLY �✓� Application Accepted by � 1^�_- __.__.---_ --_ Date. -Lam_ _—. Area_ Pit or Grout Inspection b _ Date _ Final Inspection by,---- —_— Date Additional Comments: Stk 466-6781 0 Lodi 369-3621 O Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stli CA 95201 I t FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH EH t4-28 "'-3 24 1REV i s 4") EH 1 �u4Y - y�'�^ �/ I �