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APPLICATIvN FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MACHADO, INC. P O BOX 2009, STOCKTON, CA 95201 247 N. Jacktone Road Pe f ill l v- EXPIRES 1 YEAR FROM DATE ISSUED Stockton, California 95215 (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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �/ 7 i / / � Ci City 11 Qo�ize/Acreage Owner's Name PA(/LJ/ �}'1'e.eLt �� '� Address :50. Phone Contractor 1,- Addres A012,7•-Y(c C i, P License No-it 2 2,P)ye) Phoney TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR kr OTHER O Monitoring Well L� 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I•I Public I-1 Other 11 Delta Depth of Grout Seal _ Type of Grout I I Irrigation Approx. Depth I I Eastern Surf Seal Installed by Repair Work Done F-' Type of Pump `JtiQ/_" H.P. 2 � 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 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms U , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines _ Total length/size FILTER BED (7) Distance to nearest: Well _ Foundation Property Line r\ SEEPAGE PITS 1 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, and 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 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 workman's compensa- tion laws of California." The appy must call for all re trod in ctions omplete drawing onrverse side. Signed X Title: f 0Z1k Date: //�� ^. �OR PARTMENT USE ONLY f Application Accepted by CL n k" `. U\M A,�cX!41N� Date '- 1 —�o Area _ Pit or Grout Inspection by Date Final Inspection by Date 3 -` 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH p C� 7`I f EH 13-211REV.rin5r { -- _ " — EH":1-le V V !! Y