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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION MACHADO, INC. 1601 E. HAZELTON AVE. , PHONE (209)468-31420 247 N. Jacktone Road P O BOX 2009, STOCKTON, CA 95201 Stooktgn, California 95215 QLPERMIT EXPIRES 1 YEAR FROM DATE ISUED (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 Jiloaquin County Public Health Services.l Job Address F e City r— Lot Size/Acreage Owner's Name Address Phone I� 1 Contractor Addres r License W,122) Phon TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION a Out of Service Weil Ll PUMP INSTALLATION ❑ SYSTEM REPAIR OC OTHER ❑ Monitoring Well CJ 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 I nlIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Fi Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications M I'I'Public Ia Other 171 Delta Depth of Grout Seal Type of Grout i,: �trrigaflon .M--.Approx. De th 1 1 Eastern t Surface Seal Installed by Repair Work Done,k Type•ot Pump__4 YH:P. j State Work bon _ v WlIpell Destruction ❑, Well Diameter Sealing Material & Depth ip Depth Fi11er.Material & Depth -- TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.! -Installation will serve: Residence_ Commercial T Other I ,Number of living units: Number of bedrooms C4 Character of soil to a depot of 3 feet: Water table depth SEPTIC TANK. Cl Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ d t Method of Disposal -,Distance to nearest:- Well- Foundation Property Line aft fin � ,O LEACHING LINE Cl No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Liffe � r SEEPAGE PITS l I Depth Size Number _ S IMPS 0 Distance to nearest: Well Foundation Property Line'+" DISPOSAL PONDS 0 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 empioy 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 co m ansa- tid6 laws of California." The appli must for all required in ctions. mpI a drawing onr e side. I Signed X_ Title: Date: i �F DEPARTMENT USE ONLY _ Application Accepted by I IN DateArea _ II. Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant – Return all copies to: Seal Joaquin County Public Health : i Services, Environmental Health Permit/Services 1601 E. Raaelton Ave., P 0 Box 2009, Stockton, CA 95201FEE ` INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMI7'NO, . EH,3-2,IRtV.,,ns, 5. -1 _` EH 14.1 g -..II