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SAN JOAQUIN COUNTY PUBLIC HEALTH SERYICEsPAYMENT ENVIRONMENTAL SJQ QHEALTH (209)468-3420 DIVISION445 AN UIN, HONE RECEIVED P O BOX 2009P STOCKTON, CA 95201 JAN 19 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEf�AN JOAQUIN COUNTY (Complete in Triplicate) LiCHEALEALTHSERICES ENVIRONMENTAL HEAITH DIVISION Application 1i hereby made to San Joaquin county for a permit to construct and/or install the work herein described. This application Is made in couplis.nce with Ban Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. Job Address 2500 W. Lodi Avenue City Codi , CA Lot Size/Acreage .56 Acres Owner's Name USA Petroleum Corp. Address P.O. Dox 1839 Santa Monica, CA Phoria (310) 452-620 Conlraclor Woodward Drilling Cogddress P.O. Box 336, Rio VisteitenC§e fVo. 51116 39 C-5 Phone (707) 374-4300 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service well ❑ � PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES 50' DISPOSAL FLD. PROP. LINE 75' FOUNDATION 25' AGRICULTURE WELL 500' OTHER WELL �J 30 PITSISUMPS N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial f3 Open Bottom ❑ Manteca Dia. of Well Excavation 811pia, of Well Casing 21r M Domestic/Private M Gravel Pack ❑ Tracy Type of Casing 2" SM 40 PVC Specifications Gee �b lim 11 /93 f'I Public ymitor f:l Other n Delta Depth of Grotty Seal Type of Grout int 2-111ent w/ 5° 1 I I frripation _a'Approx. Depth 1>1 Eastern Lcdi Surface Soul Installed by4�bCdd Drilling (b. tcnite Repair Work Done L3 Type of Pump N/A H,P. Slate Work Done _ Well Destruction ❑ Well Diametet R11 Sealing Material fi Depth Neat._w/5k FE�ntnrtite - silrf_,hydratrad_Ben to Depth . 60' Filler Material i Depth 60-30' #3 bbntez�y Saul 3U l9' TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Resldence_ Commercial_ Other f'1 Number of living units: Number of bedrooms N/A d 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. b Length of lines Total Iengihlsize FILTER BED Cl Distance to nearest: Well Foundation Property Line N/A II SEEPAGE PITS [ 1 Depth Size Number SUMPS LI Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS ❑ N/A 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 I employ any person In such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signstwe I certifies the fotlowinb: "I Certify that in the performance of the work for which this permlt is issued, I shall employ persons subject to workman's compensa- tion taws of California." ;L I The applicant mutt for r ire c ' Complete drawing on reverse side, p ~ a r'y President Wkstezn c;eo-Ehgineers Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by bate Area Pit or Grout inspection by Date Final Inspection by Date ; Additional Comments: Applicant - Return all copies to: San Joaquin County Public health Services Environmental Health Permit/Services { 445 N San Joaquin, P 0 Box 2009, Stkn, OA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'M0, H14-I/tR[V.IiF51 ?'� P3 00 -� 6 �� 1 T % -0/