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r <br /> APPLICATigllr FOR PERMIT <br /> ft <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MACHADO, INC. <br /> P 0 BOX 2009, STOCKTON, CA 95201 247 N.Jaoktone Road <br /> t�lvLP Pe Qo_�v REMIT EXPIRES 1 YEAR FROM DATE ISSUED StOrAtonr 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. 5179 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 142t Se- City d �o zelAcreage <br /> Owner°s Namero; k�V^ Address `e), Phone <br /> Contractor Addresspw// j. ;_d� ICJGi C- License Noi?M-4[l Phone <br /> yca <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR Ir OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDr. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom. ❑ Manteca Ria. of Well Excavation Dia. of Well Casing <br /> V_Dornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public I_l Other Cl Delta Depth of Grout Seal Type of Grout <br /> I # Irrigation _.Approx. Dep.!D I I Eastern Surf qb Seal Installed by <br /> Repair Work Done �T ' Type of Pump H.P. Z- 5 — - 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 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 /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 laws, 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, 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 /> certifiers 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 taws of California." <br /> The app)' must call for all t fired ins ctions omplete drawing on reverse side. <br /> Signed Title: Date: <br /> OR PARTMENT USE ONLY <br /> Application Accepted by r1w.` ate^ gym, p,( ��p ! _ Date — Area i <br /> Pit or Grout Inspection by Date Final Inspection by 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH REC/EIVED BY DATE PERMIT'NO. <br /> + EH13-241REV.r/Hsi <br /> EH 74.2E <br />