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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 'fo <br /> ENVIRONMENTAL HEALTH DIVISION N11 <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> YEAR FROM DATE ISSUED <br /> PERMIT EgPIRES 1 ` <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work here?dgggg,,,s <br /> This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Ref� � ,Sa n <br /> Joaquin County Public Health Services <br /> City P+Aa_ _- l <br /> ntP[` Lot Size/Acreage • 5 re`r <br /> fob Address 1 690 North 1-45 Ste. 500 �• O� <br /> E-Z Serve Petroleum Address Houston Tex 77_Q37_ Phone( <br /> Owner's Name ( 8 0 0) <br /> Address License No.563305- -Phone? D--- <br /> Contractor -.� DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL y <br /> d. WELL REPLACEMENT Cl Monitoring Well <br /> - � PUMP-INSTALLATION-❑- - ---SYSTEM REP_AIR-C7_.;­—,,,,^;..r.. OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. �` PROP. LINE J <br /> DISTANCE TO NEAREST: SEPTIANK OTHER WELL PITS/SUMPS S <br /> FOUNDATION AGRICULTURE WELL V* <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> j <br /> [I Industrial ❑ Open Bottom Manteca Dia. of Wel! Excavation_ u pia. of Well Casing— --r- <br /> Specifications <br /> Xpomestic/Private Gravel Pack El Tracy Type of Casing Type of Grout <br /> i'l Public C1 Other C1 Delta Depth of Grout Seal -- _ _ r <br /> I I irrigation J Approx, Depth I I Eastern Surface Seal Installed by C&Ad089W - <br /> Repair Work Done ❑ Type of Pump H.P. — State Work Done_ 1 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth 3E- 13' C�a,,,2., -C t G <br /> F Filler Material 6 Depth --f 2-y SANS- AL`S <br /> Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I ( lab <br /> No so! trwithine2t70 feetpe(m.) if public sower is <br /> t <br /> I Installation will serve: Residence— Commercial—Other— — <br /> Number of living units: Number of bedrooms <br /> 3 <br /> Water table depth <br /> .j....Character of soil/to a depth-of 3 feet: s r <br /> SEPTIC TANK ! Type/Mfg <br /> No. Compartments ° <br /> f PKG. TREATMENT PLT. C] Method of Disposal <br /> f Distance to nearest: Well .-Foundation---• - Property Line O <br /> t <br /> w � <br /> r <br /> LEACHING LINE Total length i C1No. & Length of lines ``5� � og <br /> o . 3 <br /> FILTER BED [.1 Distance to nearest: Well Foundation Pro <br /> �. i $lie Numb .. 1 <br /> SEEPAGE PITS I 1 Depth <br /> SUMPS C1 Distance to clearest: . Well Foundation Wdm*p"IA404�kq <br /> DISPOSAL PONDS ❑ <br /> J ,Sidi.,'t�Tifit �fttl�iai#1ies, <br /> I hereby cenify that I have prepared this application and that the work will be done in accotd state laws, and <br /> rules and regulations of the San Joaquin County rfriStfLtS1Itltid Wdfkf4'c1vhbrlilft 1iytY�'3tTafl� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the t5e►tb <br /> employ any person in such manner as to become subject to workman's compensation laws of CFAWIV �ubi pmpensa <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued,�iI � i�l <br /> tion laws of C 'fornia." <br /> t The applic st call for a Wed inspections. Complete drawing ravers side. r � <br /> iI Date: <br /> I Signed Title: i <br /> ! FOR DEPART NT USE ONLY <br /> Date v r v Area - <br /> Application Accepted y r Q �' .7 <br /> • <br /> 'Pit of Grout ate Ct ! Final Inspection by Date l �Z <br /> Inapectian by � <br /> Additional Comments: ;, <br /> l Applicant - Return all copies to: Sari'Joaquin'County Public Health Services <br /> Environmental Health Permit/Services <br /> 445.N_San-.Joaquin,-.-P•O-Box-"2009-,-Stkm;,-GA-95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> . EH11-24 tr1EV,riesl <br /> EH 14.25 <br />