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APPLICATION FeOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION MACHADO, INC. 1501 E. HAZELTON AVE. , PHONE (209)468-3420 247 N.Jacktone Road � S, P O BOX 2009, STOCKTON, CA 95201�- Stockton, Coliforr#ig 95215 PEMIT EXPIRES 1 YEAR FROM DAT ED (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. 549and 1 62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address t , City Lot Size/Acreage Owner's Name 00,/� `l re C?[n-- Address �►.�-.-- Phone Contractor AddresLicense Mo. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C3 Monitoring Well ❑ 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 C] Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing gDomestic/Private ❑ Graves Pack ❑ Tracy Type of Casing Specifications I'I Public Ci Other* M Delta Depth of Grout Seal Type of Grout I I Irti{lation _.Approx. Dept VI Eastern Surf,c Seal Installed by Repair Work Done '* Type of Pump H.P. •_. � � State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I INo septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,0 Method of Disposal Distance to nearest: Well Foundation Property Line [� V LEACHING LINE Cl No. & Length of lines Total length/size' rb FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 r 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, l shall not Q' 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 shall employ persons subject to workma comp ca- tion laws of California." Th 4icant m call for all requ' tn 'spec s. Complete drawing onP,�e side. 6" Signed Title: Date: OR PARTMENT USE ONLY Application Accepted by y ,, �R_1:L..61 Date � Area Z Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED [3Y DATE PERMIT N0, EM 13-24 ++ INFO i (REV.I/It5) EM 93.26