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APPLICATION-FOR.,PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION MACHADO, INC. <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 247 N.JacktoMe Road <br /> ... P 0 BOX 2009, STOCKTON, CA 95201 Stockton, California 95215 <br /> kEMIT EXPIRES 1 YEAR FRPM DATE ISS_)UM <br /> (Complete in Triplicate) <br /> r <br /> jApplication Is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 a c� 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health-SerAices. <br /> Job Addressa(�-f� _I City Lot Size/Acreage!23 IL <br /> Owner's Name Cry Address <br /> Phone <br /> -ti <br /> Contractor d Address ! d License No. Phone — G <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'!'; • OTHER ❑ Monitoring Well <br /> kDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Womestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> V1 Public l.7 Other � C-1 Delta Depth of Grout Seal Type of Grout <br /> i <br /> I I Irri0mion _.Approx. Depth l 1 Eastern Surface Seal Installed by <br /> Repair Work Done )9 Type of Pump Q H.P. State Work Done/,-;,,0,V1/ <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> Filler Material & Depth <br /> Depth 9 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION { I iNo septic system permitted it public sewer is <br /> r available within 200 feet.1 <br /> Installation will serve: Residence= Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: f Well Foundation Property Line. <br /> i LEACHING LINE D No. & Length of lines Total iength/size-'e <br /> FILTER BED ❑ -Distance to nearest: Well - Foundation Property Line <br /> .,r <br /> ""'SEEPAGE PITS 11 Depth Size Number '' <br /> SUMPS LI Distance to nearest: Well Foundation Property Line s <br /> DISPOSAL PONDS ❑ °1 <br /> I hereby certify that I have prepared this application and that,the work will be done in accbrdance 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: "I certify that in the performance of the work for which this permit is issued, I shall not-,gym <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify thatin the.-performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I. <br /> The nt st call for ail re d inspe ions. C plete drawing on revs a side. <br /> Signed Title: . _ j Date: <br /> R PARTMENT USE ONLY <br /> Application Accepted by Date t`fT`ro Area <br /> I <br /> ate <br /> Pit or Grout inspection by Date Final Inspection by p <br /> i Additional Comments: <br /> i <br /> i Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DOi AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> F ENt3.241REV.iiKsi L"�roO f/SHfNj qV <br /> EH 14.20 <br />