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S 'r0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEIf <br /> ENVIRONMENTAL HEALTH DIVISION A <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 f � Py <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT -MIRES I -I FROM D <br /> (Complete 1.n Triplicate) <br /> I �+Q ,r Thie <br /> Application is hereby me4e to San Joaquin County for a permit to cc strurt and/or install the work bere�d a <br /> application in made in compliance vith San Josquin County Ordinance No. 549 and 1862 and. the Rules and Be i , ,San <br /> Joaquin County Public Health services. <br /> Job Address <br /> City,Mant�ca Lot blse/Acreage rear <br /> 1690 North 1-45 Ste. 500 dO,� <br /> Owners <br /> Name E-Z Serve Petroleum Address Houston a Phone( C <br /> ( 800) <br /> Contractor•TSI Fxpl nrat"1 nn Address License No 563305 Phone <br /> TYPE OF WELL/PUMP NEW WELL V, WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR C7 OTHER C] Monitoring Well <br /> rl <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE S- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .^ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS to <br /> C7 Industrial 0 Open Bottom ^Manteca D+a of Well Excavation " Oce of Weft Ca0v <br /> Oornast+c/private Gravel Pack Tracy Type of Cas+ng_ Specifications <br /> ! I Public 1"1 Other fl Delta Depth of Grout Seal <br /> ' - <br /> S i I Type of Grout C --•r <br /> I I Irrigation _Approx Depth I I Eastern Surface Saul Installed by <br /> Repair work Oona U Type of Pump 2 <br /> HP State Work Done , <br /> Wall Destruction ❑ Wall Diameter Bearing Material fi Depth r <br /> Depth Filler Material M Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (NosSM within system Perrmloettjed if public $Ower is <br /> Installation will serve Residence Commercial_.. Other <br /> Number of kiting unite Number of bedrooms <br /> Character of sod to a depth of 3 fest Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No Compartments <br /> PKG TREATMENT PLT ❑ Method of Do"" <br /> Olsunce to nearest Well Foundation Property Lanai <br /> LEACHING LINE Cl No A Length of lanes Total length/ <br /> AAWAININT <br /> FILTER BED ❑ Distance to nearest Well Foundation ProqqEICbEfVVV— <br /> SEEPAGE PITS 11 Depth Sias Number <br /> M 92 <br /> SUMPS LI Distance to nearest Well Foundation 31AIQ1lIA <br /> DISPOSAL PONDS ❑ PUBLIC HEA( Trl <br /> I hereby certify that I have prepared this application and that the work will be done titaccorda�l 9Yn J Apuiirdstrnty�alWnanl�as, state laws. and <br /> rules and regufsl+ons of the San Joacluen county SAN inAtlYTftV� TI��� <br /> Some owner or licensed agent's signature certifies the following "I certify that in the Rfei'rarfrtfMt�ftll`tn �P� <br /> employ any person in such mariner as to become subject to workman's compensation laws of CMUO —4 rUZ'WIMQ9•1t <br /> srgnature <br /> csrtafaes the following 11 certify that in the performancs of the work for which this permit is issued,5 ir1JV�=W cornpenvit <br /> tin lawn of C ornfa" j' Lllyl. 11 <br /> The appdc a call for ed inspections Complex drawing qp ravers side Z <br /> SignedVnAIIAJTltls Due <br /> FGA DEPARTPAMT USE ONLY <br /> y <br /> Application Accepted y Data Area <br /> � I <br /> Pit or Grout Inspection by Date --- F+nel Inspection by Date <br /> Additional Comments I <br /> Applicant - Return all copies to San Joaquin County Public Health Servicea <br /> Environmental Health Permit/services t�/ <br /> 445 N San Joaquin, P O Box 2009, Stka„ CA 95201 9f <br /> FEE AMOUNT,DUE AMOUNT REMITTED! CASH <br /> 8 RECEIVED BY I DATE PERMIT Ni ' <br /> INFO' <br /> .. qg <br /> EH tu <br /> ]a�+11EV tfa <br /> EH t�as I I 1 1 I <br />� I I II to ni I I ' i� ,III I � ii�l i III i i 'I V I ,I ' ii I'I II ` i • �` <br /> i1 <br /> I I <br />