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APPLICATION, FOR PERMIT j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION t 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MACHADO, INC. P 0 BOX. 2009, 3 XTON, CA 95201 247 N. Jacktone Road Stockton, California 95215 v- EXPIRES 1 YEAR FROM "ATT ISSN (Complete in Triplicate) Application is hereby made•to Sam 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 i Joaquin County Public Health Services. 1-� Ct li r b ity Lot Size/Acreage Job Address Owner's Name �t Address � Phone Contractor Addre l c G� " License Na331f Phone f Service well TYPE OF WELL/PUMP: NEW WELL C3WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Monitoring Well ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR Lit OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications DomesticlPrivate, Cl Gravel Pack ❑ Tracy Type of Casing Type of Grout i 1 1-1 Other ❑ Delta Depth of Grout Seal I"1 Public � a 1 y I I Irrigation Approx. Depth"""-1 l'Easterrf Surface Seal Installed by �. Repair Work Done Type of Pump fd H.P• .2- State Work Dane�� C -�_ Sealing Material & Depth -�- Well Destruction ❑ Well Diameters Depth Filler Material & Depth . - TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIRIADDITION 1 1 DESTRUCTION I I (Nailableo septi syslam 200 rented ill.public sewer W. i r Installation will serve: ResidencesCommercial Other 4 a Number af_living.units: "` Number of bedrooms ��r .. .5 ` Character of soil to a depth of 3 feet:r- Water table depth i SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r _ Method of Disposal (�. Distance to nearest: Wel Foundation Property Line ._. __. - _ LEACHING LINE ❑ No. & Length of lines Total length/size k FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS y` 11 Depthf- Size 1, Number SUMPS L1 Distance to nearest: Well Foundation Property Line d DISPOSAL PONDS ❑ I hereby certify that t 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 cartifies the following: r'l cenity 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 worts for which this permit is issued, !shall employ persons subject to workman's compensa tion laws of California." I The apph nt must c for all required in , tions. mplete raving on eve/side. 31 Title: 1 f _ pate: Signed X y F DEPARTMENT USE ONLY + Application Accepted by kiA Date Area J Pit or Grout Inspection by Date Final Inspection by ate �6 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health { Services, Environmental Health Permit/Services It 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE I AMOUNT REMITTED CK RECEIVED BY DATE PERMI NO. INFO CASH �. . EH 13-24IREV.v/A61 �,Q CH 14-2b r