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f � � <br /> APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES MACHADO, INC. <br /> ENVIRONMENTAL HEALTH DIVISION 247 N. Jacktone Road <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 Stockton,California 95216 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMITXPIRES 1 YEAR FROM DATE JSaUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / <br /> Job Address ` T City Lot Size/Acreage <br /> Owner's Name L JV,_1/ ddress per_ _.._ Phone <br /> ContractorAddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USEa TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1 Public la Other C1 Delta Depth of Grout Seal Type of Grout <br /> I Irrigation _Approx. Depth l I Eastern Surface Seul Installed by <br /> Repair Work Done Type of Pump IstQ_ H.P, S� State Work Done <br /> Well Destruction ❑ Well.Diameter Sealing Material & Depth <br /> Depth " Filler Material & Depth C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.! <br /> Installation will serve: Residence_ Commercial __ Other <br /> -- <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: IN11 Water table depth <br /> SEPTIC TANK. D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ -'�� <br /> Method of Disposal <br /> Distance to nearest: Well FoundationProperty Line <br /> F l <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation. Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state:shall <br /> aws, and' <br /> rules and regulations of"the San Joaquin County <br /> 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, not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of The work for which this permit is issued, I shall employ persons subject toZOIKM 's com nsa- <br /> tion laws of California," <br /> The a m t call for all requir spec ' s. C plete drawing on a side. <br /> Signed Title: -_ .�'e _,.,.. Date: <br /> :7J <br /> EPARTMENT USE ONLY G� <br /> Application Accepted byL - N. Date `� L Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 1 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health 1 <br /> Services, Environmental Health Permit/Services �( <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED 7ASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24 IREV.1/95s <br /> EH aa•2s D V <br />