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r <br /> APDL I CAT-1-ON—FOR.,PERid IT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON1dENTAL HEALTH DIVISION MAC fADO, INC. <br /> 1601 E. HAZELTON AVE. , PRONE (209)468-3420 247 N,JacMme Road <br /> P 0 BOX 2009, STOCKTON, CA 95201 Stockton, California 95215 <br /> h <br /> Yci_"I rip-Ph, ; PERMIT E%PIRFS 1 YEAR FRAM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 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. 54P 9d, 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se ic��es�/.J1� <br /> Job Address GLttU t� City Lot Size/Acreage <br /> Owner's Name —5+ Lam- Address Phone <br /> Contractor D •Address 4..�— r License No.6 Phone G <br /> TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACEMENT C DESTRUCTION L3 Out of Service Kell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1W, • OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC YANK 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 /> f] Indusmai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (Domestic/Private C Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> F: Public C,; Otheri , n Delta Depth of Grout Seal Type of Grout <br /> I I I Irrigation —.Approx. Depth t I Eastern Surface Saul Installed by <br /> Repair Work Done aX Type of Pump H.p, State Work Done <br /> L Well Destruction 0 Well Diameter Sealing Material & Depth <br /> fI Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR1ADDITION I i DESTRUCTION ; I (No septic system permitted if public sewer is <br /> ravailable within 200 feet.) (� <br /> { ,-Instatlation will serve: Residence— Commercial____ Other <br /> I 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.Ll r <br /> '4 Method of Disposal <br /> Distance to nearest: t Well Foundation Property Line <br /> I <br /> h <br /> LEACHING LINE Ll No. & Length of lines Total length/size- <br /> FILTER BED ❑-a`Distance to nearest: Well _ Foundation <br /> . Property Line <br /> � •.1 <br /> SEEPAGE PITS I t Depth Size Number r <br /> SUMPS Ll Distance to nearest: Well Foundation Property line � r <br /> DISPOSAL PONDS O <br /> 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. <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, <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 /> certilies 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- <br /> tion laws of California." <br /> Thent st call for all rewfald ins pe Ions. C plate drawing on rave a side. <br /> Signed Title: Date <br /> ` C'^&()R nPARTMENT USE ONLY 1E <br /> Application Accepted by , � Vf�A C���7{� p N N N NA nos Date —t� Area <br /> Pit or Grout Inspection by Date <br /> i Final Inspection by <br /> Additional Comments: <br /> i <br /> I Applicant - Return all copies to: San Joaquin County Public Health <br /> ( Services, Frtvironmentsl Health Permit/Services <br /> i} 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95207 <br /> FEE AMOUNT 06E AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT N0. <br /> EM 53241REV.lixSi L"�:-'o 0 <br />