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err APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MACHADO P 0 BOR 2009, STOCKTON, CA 95201 247 N.Jacktcne Road' PFJWIT EXPIRES 1 YEAR FROM DAT ED Stockton, CA11f®►n1a 96215 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations.of San Joaquin County Public Health Services. Job Address tai City � Gt Lot Size/Acreage Owner's Name /L ti[` �A.f.� Address,)749_ _ Q� Phone Contractor, iLTA f Address ! a Jc!drtp T_License NPhone �-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well �) PUMP INSTALLATION 0 SYSTEM REPAIR'- OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XDomestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public f-1 Other 171 Delta Depth of Grout Seal Type of Grout I i Irrigation _.Approx. Depth Ih Eastern Surface Seal Installed by 1 Repair Work Done �< Type of Pump _ H.P. State Work Done d J Weil Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f 1,-t DESTRUCTION 1-1 lNo septic system permitted if public sewer is r i'available within 200 feet.) Installation will serve: Residence— Commercial— Other 4 llt Number of living units: Number of bedrooms ` f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.. Compartments PKG. TREATMENT PLT. ❑- F ' Method of Disposal Distance to nearest: Well Found4 ation Property Line LEACHING LINE ❑ No. S Length of lines Total length sue p� F I FILTER BED ❑ Distance to nearest: Well Foundation I Property Line I SEEPAGE PITS 11 Depth. ' Size . .- - .-:'Number. - ._ . . . .- - �:• SUMPS LI Distance to nearest: Well Foundation Property Line"* DISPOSAL PONDS ❑ t 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in.the.performance'of the work-for which this permit is issued, I shall employ persons subject to work ma ' com ansa- tion laws of California." The appli t mu call for all requited pection 0 drawing on rev,#s side. �. Signed Title: C. Date: D6PARTMENT USE ONLY 41 Application Accepted by <,2\ ,ne -' Date h- Area Pit or Grout Inspection by, Date Final Inspection by Date 1! Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health r Services, F�avironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + E 13-21 tAEY.t i n SY �[' [ /� q—1—;o cl 0 —aJ.! ' EHH 11.24 :7 11 (/ V fj`( l