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Environmental Health - Public
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3500 - Local Oversight Program
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PR0545337
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Last modified
2/11/2020 8:09:10 PM
Creation date
2/11/2020 11:26:45 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0545337
PE
3528
FACILITY_ID
FA0003629
FACILITY_NAME
ARCO STATION #434*
STREET_NUMBER
501
Direction
W
STREET_NAME
KETTLEMAN
STREET_TYPE
LN
City
LODI
Zip
95240
APN
03119028
CURRENT_STATUS
02
SITE_LOCATION
501 W KETTLEMAN LN
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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APPLICATION FOR WE UMP PER(. 1 <br /> S: N JOAQUIN COUNTY PUBL C HEALTH SERVICES <br /> ENVIRONMENTAL H TH DMSiON <br /> 304 EAST WEBER AVENUE, OCKTON,CA 55202 <br /> (249) 0 <br /> 101-FIEFUXUAStE PERItl7 EXPIRES YEAR FROM DATE ISSUED <br /> mnn"La Is Tr Sernl <br /> APPLICATION 16 HERE VY M^IX TO TME SAM JOAAtmI COU+RY FOR A P8 Rt TO CONSTRyIC.T R INSTALL TTIC WORK OFYCRMEO.THRT APPLICATION to YALE+M CO&v tfAMCE Art I t$AM <br /> JOAOUIM COUNTY OEWLOPUDIr Trn.E.CHAP 9-1 AND YHE T T S.3 AsTAMOAP09 OF g A PU6LIC HEALTH gowvx:B.EMSAt NMEWAL HEALTH*M=td_ <br /> JOG:AOOR'F S"IOF APWS 10� ; l3 33 5 ` - 11 - <br /> Agl r) <br /> QwNI,�" MArtE AoatREgi I ZIIE �C,1[i r.nl7 i <br /> RS r Aa01t526 l QT- rL.,P6 6 <br /> �F COMYfUlCT071 AaO� - 7� <br /> l <br /> :YPeOFv�tJptulP ❑ ++EwwELt ❑ lrlPucENexTweft ❑ F+oH/ra wain-i[~1^-1i ���'� oTr�x II <br /> ❑ M6rAuATsom ❑ WCLL weaTEN A£PAm Q C1+D CT vers a VAP04 EXTtv=naM VjtLL f <br /> Q N—Cl Pce.M H9. 06 TR Krur so F4ffiT WATER LEVEL O 1 <br /> (TYPE OF PVNPI <br /> CI o TrOR.EWlnCE[IMU ©of WELL, Q 'SOIL SOItIHG�� e <br /> DFSTPtICTIOM; <br /> IFT&42t-]u2i Yp(OF WBL COM&re vO11 jvecviCAn Ni tr <br /> ❑ UIDt1GTWAC ©Ooelf SOTTOIit CIA.OF'At ETCAVATtOM M&OF Co"WCTOM CASWO�._ 0 <br /> ❑ OOI.lEFITIC/PSaVATE 0 ataAvEL PACKISgf TYPE OF CA'&"J aTFETJPVC OUL OF WELL CAS MO a <br /> Cl PVCtJCA WUX:lrAL Ej Omva, DEPTH Oa arm"SEAT 2"CIFZI'&TIOM R <br /> 0 IAwoAmwAa Q D'T71EYl GROUT Cut wwrAmm 6Y OPOVT SRAMO MAM9 <br /> Cl momrrOmmo 900VT SEA) PUNL4O_�Y ❑!I. CCMCWM PE XW^L 8Y DRUMM CI Yw Cl M. S <br /> A,PROIC_DEPTH U3CXJMG CWW713R 8OXnnXr4e Pqr s <br /> mOlowEn COMOTRVCrtOMIDMUM WFF0012: LAM ROTARY - AM AOTARY M1GM OTHER <br /> I ME4ESY CEKMv THAT T"AVE PIEp^rtM THs APIRJCATIOM AMO THAT THE WOM,w4L SE.DOME ACCOMAMM WITH SAM JOAOtRM COUNTY Q@OWAltCEs_STATE t INS.AM RUES AMD <br /> IT£CULAYTOMS OP TME DAM JOAOUIM COIMIY. Home O%vmfR OR L=NSEO AOEMr's SIGNATURE CS MPM TME F MOW04W.I CEWFR THAT IM TW PERTOMIAMCE OF THE WOM FOR WTIIGM <br /> THIN PERLaT 18 ISSUEO.1 smAa Mar SIUPLOY VEPDOMS RUSJWr TO T110R>W"-6 CPMP0ItAT1099 LA WS OF CAt"M&A.' CONTRACTOtrs WM M OR SXTO COMTRACTIMG=GP4kTLrtS CERrwMg <br /> Tote gOLLOw•MQ: 'I CERTIFY THAT W THE PEF 40m9AMCE OF TW wON(FOR WNICH Tws PEr"t f I I"UM,I WALL ULNIWT PErtoOKS OUR/£CT TO WWtOAArs CommNaAMPO lAws Of . <br /> CA"W sll.l' AMticAlfT"KRO CA14 24 OWN'an Aav4MCs/Dw AtL RECUIRM 0nLv6cTknwd Ar Ctem AcO-Vaa. COvet M 0*Awot6 AT LOWER AmEA.PwOVIDFb. <br /> Telt. e; T 6el�qiq <br /> not P APF 0. to seryl iar. to <br /> I. MAWS OP g OEFTS OR POAIM MEAFETIC TO OR SOMFOIMO THE f"014NM 4.IOCAMN CF HIMM IRWA 91 OtMPVSAL SYTrkW<rR vROP06E0 <br /> 2. OVrLME OF T/+B FPOPW".GnAM6 VM9tWmOMi AMO NORTH*R%CTIOM- OmAMS10M cW SEWAOE DUWOSAL 8TwrEMts. <br /> ]. Otmem ouM olmp rss AMC LOCATION 00 ALL 002rmm AND am S. tOCATIO"OF WEt LB WSTHW RAORIS OP OPIB MbaMEM&WTY FT. <br /> STpUCTtM&0nLVOV4g 4=%fffffO AFQIAS GUfH AS PATla4 OfVw!EWATB.AMO WAMS. OM nee vFmope y OR AOJOpma PPOPFArT, <br /> ACRID °lin .. <br /> (f�ARL 81TUSIGOMT <br /> .men—ft....ar wq d �-� a- I` °t 4 2 <br /> Y..emna..ST <br /> O.er vk~ S7 IIr. <br /> O�e..�13e..Wleeett�ST <br /> ACCOVltTFMO O10.Yt Am, FAG, <br /> >R COMA TFifO AFA*UffT FEIISTTEO C74iCIC,ICA&H IIECSVEO S• OAT[ ►9WRTRi6tvTCE REO{tE37 i1VJis81 tIfMlOtCi <br /> WA.HeslEl$Gfv.-Emvi--173(IM <br />
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