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APPLICAtION. FOR PERMIT <br /> -SAN JOAQUIN-COUNTY PUBLIC HEALTH SERVICES <br /> MACHADO, INC. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> � <br /> ne Road <br /> 1601 E 9)468 <br /> . gBOX 2009�,vSTOC&TON, CAEPHONE 95201-3 <br /> Stockton, C31€O247 N. Orn is 95215 <br /> E%P RES 1 YEAR FR M D E <br /> (Complete Ifs Triplicate) This <br /> uin County for a permit to construct and/or install the Rulevorks <br /> herein u ationsdof San <br /> Application is hereby made,to San Joaq + <br /> lienee with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Aegis ^4 <br /> application is made in compliance <br /> Joaquin County Public Health Services• n <br /> Lot Size/Acreage i <br /> �. City <br /> Job Address — <br /> Phone <br /> Address <br /> Owner's Name�� <br /> Phone <br /> Address b!e,___e_License No. <br /> Contractor DES ❑ put a2 .Service Well ❑ <br /> NEW WELL ❑ WELL REPLACEMENT Cl OTHER ❑ Monitoring Well <br /> TYPE OF WELL/PUMP'. SYSTEM REPAIR ;�r_ f <br /> PUMP INSTALLATION ❑ DISPOSAL FLD.�-- PROP. LINE <br /> SEWER LINES __ PITS/ 'UMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL.��--- <br /> a�� FOUNDATION �-- <br /> w. ; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing _^--- <br /> INTENDED USE` ❑ Manteca — Dia. of Well Excavation <br /> L7 Industrial i ❑ Open Bottom Type of Casing Specifications.— <br /> C] Tracy Type of Grout <br /> Gj>�omestic/Private ❑ Gravel Pack n Delta Depth of Grout Seal <br /> I'i Public I:1 Other <br /> x. Surface Seal Installed by. <br /> ` I irrigation Approx. Depth 1 I Eastern _ State Work Don <br /> Type of Pump -�>> � H.P. <br /> I Repair Work Done �-- Sealing Material & Depth ; <br /> Well Destruction fl Well'Diameter Filler Material & Depth r' <br /> Depth <br /> lk ,4 available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION, �EPR� QDION DESTRUCTION l I (No septic system permitted it public sewer as <br /> A ommercial Other <br /> Installation will serve: Residence.�._•-Cw <br /> Number of living units: Number of bedrooms b Water table depth <br /> Character of soil to a depth of 3 feet: Capacity—- No. Compartments r <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> �,.x�PXG. TREATMENT PLT. fl Property Line --- <br /> Distance to nearest: Well Foundation_r��—.— ^� <br /> Y I Total length/size <br /> LEACH)NG LINE D No. & Length of lines _-•,, Property Line _ �--- <br /> Foundation Property <br /> BED n Distance to nearest: Well ; 1 <br /> 1p <br /> Sire ` Number <br /> SEEPAGE PITS 11 Depth Property Line <br /> k Foundation --- <br /> i>» SUMPS hl Distance to nearest. Wel! _ <br /> f <br /> DISPOSAL PONDS © ' <br /> t I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,sssued, I shall not <br /> f Y <br /> rules and regulations of the San Joaquin County signature <br /> Home owner or licensed agent's signature certifies the following: "f certify that in the performance of the work for which this permit <br /> employ any person in such mannhat nth�tiormen�e of othe work for which this permit nsation Vs of California."s issued, I shall hiring or sub to oorkman'sgcompensa <br /> certiliss the following: "I certify t Pe <br /> tion laws of California." <br /> The applican all for all required ins ctions. mpl a rawing an reverse side. <br /> � :.pate: <br /> i Title: <br /> Signed X .. <br /> F DEPAR li:-ONLY <br /> Date `J �'-"� v Area <br /> Application Accepted by <br /> Date��---- Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: ioasCounty PublicHealth <br /> rv , EnvnnielHealthPermit/Services <br /> l 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 �Ll]E <br /> CK RECEIVED BY DATE PERMIT N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED GASB <br /> i INFO <br /> r EH 13-24 IREV.1/M$I L G_0_0 f I <br /> EH 14.20 <br />