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y� APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION JUL 2 3 �`�' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 SAN JOAQU I N COUNTY PUBLIC HEALTH H SEI VICES 2ERYJT EXPIRES 1 YEAR FRQV__1)A2:g ISSUWIRONMEiNTALHEAL',iOIViSiC)�I (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install'the vork herein described. This application is made in compliance vith.San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 601 E. Kettleman :Lane City Lodi Lot Size/Acreage ; Owner's Name Unocal Corporation- Address P.O. Box.5155,_ San_Ramo n,_-CAPhone 415 277-2341 3233 Fitzgerald Street (C57) Contractor West Hazmat Drilling Address Rancho Cordova, CA 9574Zicense No. 554979 Phone 916 638-727 TYPE OF WELL/PUMP: NEW WELL W WELL REPLACEMENT ❑ DESTRUCTION.❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK >100, SEWER LINES 351 DISPOSAL FLD. > 100 PROP. LINE 15' FOUNDATION 4 10' AGRICULTURE WELL I 100 r OTHER WELL X50 r �PITS/SUMPS 10' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t L1 Industrial ❑ Open Bottom 0 Manteca Dia. of Wall Excavation Dia. of"Well Casing 2rr ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy .. Type of Casing PVC, SCH 40 Specifications 11 Public C1 Other N Delta Depth of Grout Seal 35 r Type of Grout Neat Cement f� I I Irrigation 44Q.IApproa: Depth I I Eastern Surface Seal Installed by Tremie method Repair Work Done EJ Type of Pump WA H.P. _11A__ _ _ State Work Done„ N A Well Destruction ❑ Well Diameter Sealing Material dr Depth Depth <90 r Filler Material Depth r i TYPE OF SEPTIC WORK: NEW INSTALLATION,1 I REPAIRIADOITION I I DESTRUCTION 1 I INo septic system permitted it public sewer is N/A available within 200 feet.) Installation will serve: Residence Commercial_____ Other Number of living units: Number of bedrooms r 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 r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED N/A 0 Distance to nearest. Well Foundation Property Line i SEEPAGE PITS 1 I • Depth Site Number SUMPS N/A- El Distance to nearest: Well Foundation Property Line } DISPOSAL PONDS O 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 County ` 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 t employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I cartify 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." i The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Staff Engineer Ddte. 7/19/91 iL FOR DEPARTMENT USE ONLY' - - Application Accepted by _ Data Area # C Pit or Grout Inspection by Date FinalBlnapection by Date 0•7-1 -f Additional Comments: oze�<_Z5 Applicant - Return all copies to: San Joaquin County Public Health . g �!J''Services, Environmental Health Permit/Services7' 1601:E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 FEE 41 t INFO AMOUNT RUE AMOUNT REMITTED CASH R D BY DATE PERMI7'NO. II : EN rI.',,L'2624 iREV.t i x ai del& An 2 �_ * � +s y�f., 9/.-1143 EN •Ie