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APPLICATIt] FOR PERMIT l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION MACHADO, INC. <br /> � <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 247 <br /> N.Jacktone <br /> { I P O BOX 2009. STOCKTON, CA 95201 Stockton,Callforriis 95215 <br /> 0.tIv�PQ�tJl, I r EgP RES 1 YEAR FRd DATE <br /> 1 r (Complete in Triplicate) <br /> 1y Permit to construct and/or install the work herein described. This <br /> Application is hereby tae,de.to San Joaquin Count for a <br /> tions of San <br /> application is made in coWliance frith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Rego T <br /> Joaquin county Public Health Services. <br /> City So- <br /> Size/Acreage <br /> Job Address <br /> Phone i <br /> b A a Address I <br /> Owner's Nam <br /> �tti —__License No.�.��Phone ID � <br /> v Address- <br /> WELL REPLEMENT ❑ DESTRUCTION ❑ Out <br /> service well L <br /> Contractor AC <br /> monitoring Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ '. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ; <br /> SEWER LINES �----- DISPOSAL FLD. PROP. LINE <br /> K <br /> DISTANCE 70 NEAREST: SEPTIC TAN - OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM M AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Dia. of Well Exca <br /> CI Industrial Open Bottom El Manteca vation Specifications - <br />� $d,Domestic/Private D.-G, C4 Trac ravel Pac� Y Type of Casing Type of Grout <br /> Cl Other n Delta Depth of Grout Seal <br /> 1'1 Public Surface Sea{ Installed by <br /> I I Irrigation .—..Approx.,Depth I 1 Eastern State Work Dane <br /> H.P. <br /> Repair Work Done 1 Type of Pump -- Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> Filler Material & ])epth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITjc 1 1 DESTRUCTION 4 I (No Savailablelw within feet.) if public sewer is <br /> Installation will serve: Residence :. Commercial Other r <br /> Number of living units: Number of bedrooms__ __ Water table depth <br /> Character of soil to a depth.v 3 feetCapacity _�_ — No; <br /> Compartments _ <br /> SEPTIC TANK. ❑ Type/Mfg _ _ - Method of Disposal (% <br /> PKG. TREATMENT PLT.❑ ; } ' Property.Line <br /> Distance to nearest: Well Foundation --- <br /> f 1 <br /> QD <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length df lines% Property Line <br /> FILTER BED n Distance to nearest. Well foundation <br /> .�,,. Number .r <br /> SEEPAGE PITS 11 Depth K Size Property Line <br /> U Distance to nearest: `'Well Foundation <br /> SUMPS f, . <br /> DISPOSAL PONDS ❑ + <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 to `" <br /> Home owner or licensed agents signature certifies the following: "I certify that in the performance of the-work for which this permit{s issued, l signature <br /> shah not <br /> s of <br /> certifies the personfollowing:such"I <br /> certify art manner <br /> that n the performancecof to <br /> workforch compensation <br /> permitvs issuedlft shall employapA�sonsls'ubjnj ecrt tabwarkman`scompensa- <br /> tion laws of California." ons. C plate dr - <br /> The ap nt mus call for all to ed inspec awing on se side.Title: <br /> ` Date: <br /> � d �_T� <br /> Signed <br /> FO PARTMENT USE ONLY tar a <br /> Date �` ' L� — Area <br /> Application Accepted by u0 �� <br /> t Final Inspection by Date <br /> Pit or Grout Inspection by Date —— <br /> . � <br /> Additional Comments: <br /> 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 /> CK RECEIVED BY (SATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> 1 <br /> INFO <br /> EH 13-24 IREV.t/n 51 ✓ C- L `�f <br /> EH 14.25 <br />