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APDL I CAT h OId FOR PERM I T <br /> Af� SAN JOAQUIN' COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MACHADQ, INC, <br /> ` P O BOX 2009, STOCKTON, CA 95201 247 N.,lacktone Road <br /> PERStockton, C&IRO nia 95215 <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> III (Complete in Triplicate) <br />! Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Ilk application is made in cotspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> iI5 'Be <br /> I Job Address L <br /> n . <br /> City sr r+ '-1115T-Size/Acreage <br /> r <br /> If Owner's Name Address Phone <br /> Contractor Address 1!)LY2 �c �c.l�- � License No�3��6 Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C1 SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIVANK SEWER LINES_ DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARfA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia' of Well Casing <br /> Domestic/Private ❑ Gravel Pack 177 Tracy Type of Casing Specifications <br /> I'I Public C1 Other Fl Delta Depth of Grout Seal Type of Grout N <br /> i I hriUation _.A'pprox, Depth I Eastern Su Seal Installed by ` <br /> Repair Work Done ` Type of'Pump H.P. _- State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth, Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I f DESTRUCTION f I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: tw ' <br /> Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity' No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation L±_ Property Line <br /> LEACHING LINE 0 No. & Length of lines �. Total length/'size 'x <br /> FILTER BED CI Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire • ' Number <br /> SUMPS LI Distance to nearest: Well Foundation Proms <br /> party Line <br /> DISPOSAL PONDS ❑ ,. <br /> I hereby certify that I have prepared this application and that the work will,be done in accor <br /> rules and regulations of the San Joaquin County dance with,San Joaquin county ordinances, state laws, and <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 <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 shall employ persons subject to workman's compensa- <br /> tion laws of California." -_, <br /> The appl' t m call for all requir ' spec ' ns. C plate drawing on rse side. <br /> Signed X Title: Date: <br /> =ENT USE ONLY <br /> Application Accepted by Date_ = Z— Area <br /> Pit or Grout Inspection by Date Final Inspection by i <br /> Date <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services { - <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO, <br /> + EH 13-24(REV. n 5) <br /> EH 91.26 (� L/ 1✓e�..I�.�r ,� R 9]_?Ah <br />