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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION MACHADO, INC. 1601 R. HAZELTON AVE. , PHONE (209)468-3420 247 N. Jacktone Road � ,*✓ P 0 BOX 2009, STOCKTON, CA 95201 SWinktonr Callf(ynia 95216 PERMIT EXPIRES 1 YEAR FROM_DATE ISSUED (Complete is Triplicate) Application is hereby spade 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.] �� f�o t/ Cit rr DootSiz Size/Acreage Job Address Yr-, Lg Owner's Name Address ,,n. 7 .��- '� Phone Contractor Addressee UL��, i Cc^ 'Q _ License t�o.� �-Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT %1 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION E] SYSTEM REPAIR a OTHER ❑ 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 SPECtFICATIONS C.7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _t*-Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications F I Public (a Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _- Appfox. Depth t I Eastern Surface Seal Installed by Repair Work Done I$ Type of Pump 5 H.P. 3 State Work bone Well Destruction ❑ Well Diameter Sealing Material & Depth �] Depth Filler Material & Depth 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I iNo septic system permitted H public sewer is Q available within 200 feet.) �J 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 t SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line � LEACHING LINE C1 No. & Length of lines _ Total length/size FILTER BED (7) Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) 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, andrC� rules and regulations of the San Joaquin County 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 employ any person in such rnanner 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 workman's compensa- tion laws of California." The applicant all for all requirespec ns. Complete drawing on rave ide. Signed 7 r ? Title: __ tS Date: Zd 0 PARTMENT USE ONLY Application Accepted by Date ` �� Area Pit or Grout Inspection by _ Date Final Inspection by��. � / Data 7 / i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERMITNO. EH 13-24(REV.I i n 5i EH ..�e r o� y 9 fZ-�� 9a —2�t