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PZ <br /> APPLICATION FOR PERMIT <br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION MACHADO, INC. <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 247 N. Jack#one Road <br /> Pie 04, t 1. P O BOX 2009, STOCKTON, CA 95201 StOC4t6n, Cdiifornia 95215 <br /> Ia _ EXPIRES 1 YEAR FROM DATE IS811ED <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 trade in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ^C Q`Gt7rSize/Acreage <br /> Job Address �✓ City <br /> q <br /> Owner's NamY S -Address - Phone en <br /> Contractor �L I G- Addres e License No. Phone <br /> TYPE OF-WELL/PUMP: �� NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR J OTHER ❑ Monitoring Well [3 <br /> DISTANCE TO NEAREST_ SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial 0 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ G`avel Pack L7 Tracy Type of Casing Specifications <br /> f'I Public I:1 Other FI Delta Depth of Groui Seal Type of Grout <br /> I I Irrigation r 1�Approx, Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump 5�_ H.P. State Work Done 0r� <br /> Well Destruction ❑ WalI Diameter t Sealing Material & Dt pth <br /> i <br /> Dept <br /> llh { Filler Material & I) F'th <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/AODiTION I } DESTRUCTION I i iNo septic system permitted it public sewer is d <br /> available within 200 fist.I <br /> k y <br /> Installation will serve: Residence Commercial Y Other <br /> Number of living units: �p' Number of bedroomst �. - ��` Y., 9 � �. <br /> Character of soil to a depth df 3 feet: : ^% Waterliible depth <br /> SEPTIC TANK - 0, Type/Mfg Capacity- No. Compartments <br /> PKG. TREATMENT PLT. 0.. 'e Method of Disposal <br /> Distance to nearest: Well Foundation `" J Property Line <br /> x.. <br /> r LEACHING LINE wa 0 4s o. & Length of lines Total length/sire` <br /> FILTER R BED .,Lk Distance to nearest: Well Foundation '` Property Line <br /> SEEPAGE PITS _. lrvl� <br /> r <br /> Depth Size _ Number <br /> SUMPS ,. L3 Distance_to nearest: Well Foundation Propertil'une <br />' DISPOSAL PONDS D !11 <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: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such rhanner as to become subject to workman's compensation laws.of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit s;issued, I shall employ persons subject to workman's com ansa- <br /> tion laws.of California." II +� <br /> The appf must atI for ell requi inspec ns. Co plate drawing on r se side:, <br />+± Signed X ' Title: �t; s Date: <br /> ' I Ak <br /> DEPARTMENT USE'ONLY ;,, '• w�` <br /> a k. <br /> Application Accepted by f Date Z� L� Area <br /> Pit or Grout Inspection by I! Date Final.Inspect by Date <br /> ` Additional Comments: I x <br /> Applicant - Return 811 copies to: San Joaquin County Public Health <br /> F Services- Environmental Health Permit/.Services <br /> I, 1601 E. Hazelton Ave., P 0 Box 2009','=Stockton, CA 95201 <br /> :. �. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK };R RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 13-21 IREV.1in51 EH 14.26 <br /> ` <br />