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APPLICATION J' I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI ENVIRONMENTAL ZEALTH DIVISION i 445 N SAN JOAQUIN,' PHONE (209)468-3 0 Com' P O BO% 2009, STOCKTON, CA 95201 !?J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L,f` (Complete in Triplicate) �� 1rC Application is here made to San Joaquin Count for a pP by f 4 y permit to construct and/or install the work he� d. This application is made in compliance with Sas Joaquin County Ordinance'No. 549 and 1862 and the Rules and f San Joaquin County Public Health Se ices.. . Job Address r City S�_nr-kt0n Lot Size/Acreage Owner's Name E—Z Seryp fil.roleum Address 1 0700 North T-"45_ Ste 500 — Phone7 — _- - Houston, Texas_77037-1187 Contractor Address _ 'License No.5-6 3;�0.) Phone — `A66 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTE REPAIR ❑ OTHER 0 Monitoring Well �{ DISTANCE TO NEAREST: SEPTIC TANK +SEWER LINES a DISPOSAL FLD, PROP. LINE I s-FOUNDATION %, PAGRICUL'TURE-WELL.- ` "-0THER'_WEt.L- PITS%SLIMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CON STIR UCTION:SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation r` Dia. of Well Casing Domestic/Private ;&Gravel Pack* ❑ Tracy Type of Casing -PV Specifications ["l Public 1-1 Other n Delta Depth of Grout Seal Type of Grout iei� I I Irrigation Approx, Depth I I Eastern Surface Seal Installed by s- cAa rR �} Repair Work Done 0 Type of Pump H.P, "+ tate Work Done Well Destruction ❑ Well Diameter " Sealing Miaterial & DeptheaaT;Ga+eTF — (, �� 'fig r Depth___M',6, . _ Filler Material & Depth Y rc -- 6 0 r TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is SAN JOAQMN MftW'D'FL�f61EALTH SERVICES Installation will serve: Residence^ Commercial^_ Other ENVIRONMENTAL IIL•LH DIVISION l Number of living units: Number of bodrooms Character of soil to a depth of 3 feet:_ SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments i PKG, TREATMENT PLT. ❑ `" '^° --*- Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Len' th of lines g Total length si ai�rr FILTER BED F1 Distance to nearest: Well Foundation Pro grrt . SEEPAGE PITS -IAI Depthl Size Numb SUMPS -: LI""Drs"tarice to nearest: Well Foundation J O Y DISPOSAL-PONDS _ 0— ____ - t rAM L r-i I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin-county ordinances, state laws, and,. rules and regulation's of thea"Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that imthe performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- tion laws of California." The appli a ust call for u'ed i pections. Complete drawing on reverse side. � r Signed X >"LI Title: Registered Geologist Date: May 1 2, 1 992 F R DEPARTMENT USE ONLY _ Application Accepted by Date Z �+�2 Area Pit or Grout Inspection by t a� !S <Z-pffi°el Inspection b ` (/f C Date 6 Additional Comments: �Dr 6 ► r Applicant - Return all copies to: San Joaquin County Public Health Ser ces U400 Environmental Health Permit/Services �} f 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEEi INFO AMOUNT DUE r AMOUNT REMITTED LASH RECEIVED BY DATE PERM17'ND. . EH13-24(REV.r/nen EH 14-28 f }