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L1 <br /> { 1'S APPLICATION +ti <br /> 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI P ENVIRONMENTAL HEALTH DIVISIONY )) <br />' 445 N SAN JOAQ€IIN, PHONE (209)468-3�$0 1F�� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I$SUED <br />' (Complete in Triplicate) Ile lrG' <br /> Application is hereby made to San Joaquin County ror a permit to construct and/or install the work he d This <br /> application is made in au *Bance with San Joaquin County Ordinance No 549 and 1862 and the Rules and o2f'San <br />' Joaquin County Public Health Services <br /> Job Address <br /> ___ City Starktnn_ Lot Size/Acreage Gf�� <br />' <br /> Owners Name E-Z Serve Petroleum Addressf i - Phone7—A --..95 <br /> Houston, Texas 77037-1187 &6 <br /> Contractor Address f License No X63 A0q----- PhoneQQ�•� <br />' TYPE OF WELLIPUMP NEW WELL WELL REPLACEMENT !i DESTRUCTION ❑ Out of Service Stell 0 <br /> t=.jml" INSTALLATION ❑ SYSTEM, REPAIR ❑ OTHER p Monitoring Ve:l r,( <br /> DISTANCE_ TO NEAREST SEPTIC TANK SEWER LINES6 n� DISPOSAL FLU PROP UNE I <br /> FOUNDATION t AGRICULTURE WELL — OTHER WELL _ °ITSlSUMPS <br />' INTENDED USE _T%` OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS — .t <br /> n �ndustnal U C�,r�� 8urrom ❑ Manteca Dia of Well Excavation_ r` — Elia of We Casing <br /> KDomastic/P Ovate Xa ec—it Pack ❑ Tracy Type of Casing- C Specr'ications <br />' { I Public ; Ot-1a+ n Delta Depth of Grout Seal Typo$ of Grout <br /> i I leoit}ation -- A+pro& 0opth i I Eastern 5urtace $eel Insiarlou by <br /> Reoair Work Dore U Typo$ t' Pump H P State Work Done <br />' Well pestrucuen C, +'+le+i F,iarneter Scaling Material i Depth rL � •* � { _� ' <br /> r <br /> Depth ` Filler Material i Depth -+ <br /> "IyrE OF SEPTIC WORk NEW NSTA,LATION i I REPMAJADDiTIOR ' i DESTRUCTION I I INo septic system permi[tad d pub++r, sower is <br /> M SAN JOAQU I%'tCb"emit:41`EALTH SERVICES <br /> Installation will sore Residence ___ Commercial _.___. Ot,sr ENVIRONM NTAL HEALTH DIVISSION' <br /> Ni.mber of l onE +snots _ Number at bedrooms y <br /> Character at sod to a depot of 3 teat _ „_ - -- �- I <br /> ARRMT <br />' SEP7.0 TANK C Type/Mfg -- Capacity No Compartments <br /> PKG TREATMENT PLT 0 Method of O+spomil <br /> Distance to nearest Well Foundation Propertty Line <br />' LEACHING LINE LI No 6 Length of lines Total Iengthlsi� '"- <br /> FILTER BED is Distance to nearest Well Foundation Proj �_ <br />' SEEPAGE P;TS t I Dapth Sue Numb I 4 <br /> r lt;vCL)JyIf <br /> SUMPS / LI distance to nearest Well Foundation . � p lr r iyr►I6.1� <br /> DISPOSAL PONDS U �r - - <br />' I hereby comity that I have orepared this application and that the work will be done in accordance with San Joaquin county ord.nan_es stater laves, anti <br /> rules and rep.►lalions at the San Joaquin County <br /> Home owner or licensed&Anne's signature cartiba3 the following "I carity that in the performance of the work for which this parrot is tasued, I shall not <br /> employ any person in Birch runner au to become subject to workman s compen"t+on laws or Csidoinia ' Contractor a hiring or tub-contracting signature <br />' canifies the following "I ct-ni'y that in the performance of the work for.%Itch this permit is Issued I shall employ oersonr,subject to workman a comoonsa <br /> tion laws of CaMornis ' <br /> Teta applea use rel; iof ei' a ed inspections Compte+e drawing on rave{se side — <br /> SlgneC '� ~f/r Title Registered Geologist Date may 1 2 , 1 992 <br /> FPR DEPARTMENT USE ONLY _f <br /> Applitolion Acceoted by � Date 2 _ Area <br />' P+t w Grout I^apecrron by oate Final 1^apawion by Data <br /> Additional Comments tsA 1 , \ � •^ A my <br /> aA <br /> Applicant - Rh L-c at , ccpier: to San Joaquin County Public ilealth Serd'ices <br />' environmental i.eal.th Permit/3ervices o J <br /> 445 N San Joaquin, p O bo-c 2009, Stkn CA 95201 <br /> r <br /> CX —i <br /> IEEE 4 AMOLANT DUE A'4t0UNT REMITTED CASH RECEIVED BY I DATE ^aERMiNO <br />' I �0-� Lam, ��]] <br /> En ill74 tRtV "n si + / / r�+ r <br />