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APPLICATION,FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MACHADO, INC. <br /> P O BOX 2009, STOCKTON, CA 95203 ! <br /> 247 N. Jacktane Road <br /> pgRMIT EXPIRES 1 YEAR FROM DATE ED Stockton, California 95215 <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 1 62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ,t <br /> t <br /> } City - [ Lot Size/Acreage <br /> Job Address4�0 <br /> Q OAddress /`�' Phone <br /> Owner's Name ,i <br /> Contractor <br /> 6.. d Address License No' LPhon — a t <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 Out of Service well ❑ <br /> SYSTEM REPAIR OTHER ❑, Monitoring Well <br /> PUMP INSTALLATION ❑ e9t 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.—__--r PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fel'-Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Spedifications -- - <br /> I'I Public L] Other n Delta Depth of Grout Seal Type of Grout <br /> I I Eastern Surface Seal Installed by <br /> I I Irrigation —.Approx. Depth <br /> Repair Work Done 60 Type of Pump H.P, --✓ - State Work Don <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth. <br /> TYPE OF SEPTIC WORK;' NEW INSTALLATION I I REPAIRlADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> - ti t f -—ivailablef within 200 feet.I <br /> installation will serve:a Residence Commercial Other'"'' <br /> Number of living units: Number of-bedrooms a Y <br /> k , <br /> Character of soil to a depth of 3 feet: Water table deptf: <br /> SEPTIC TANK ❑ 1 Type/Mfg ,.Capacity No. Compartments � <br /> PKG. TREATMENT PLT. 0 r�X Method of Disposal <br /> r ti Distance to nearest: Well Foundation Property Line <br /> i t.1 <br /> LEACHING LINE Lel `No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line i <br /> i r <br /> 4 SEEPAGE PITS t I Depth Size _ Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ILI <br /> I hereby cavity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and a <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, I shall not�1+ <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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 compe sa- <br /> tion laws of California." <br /> The appl' t m t call for all required i ction Com a drawing on r ers side. <br /> k Signed Title: _ �,� --- Date:* <br /> FOR ARTT USE ONLY <br /> r s <br /> Application Accepted by Date Area <br /> 13 <br /> o t <br /> Pit or Grout Inspection by Date Final Inspection b t -- Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> f Services, Environmental Health Permit/services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 NO. <br /> Ilt INFO (} <br /> + EN 13-24 PIEV.I R alLts T r —17--q <br /> EH A-26.2E t 0 <br /> 1 <br />