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APPLICATION FOR PERMIT <br /> I' <br /> SA�OAQUIN COUNTY PUBLIC HEALTH `,—_AVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in 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 and 1862 an the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 2130 West Washington Street City Stockton reage 2130 West Wash �`c�l t 209 466-4391 <br /> Owner's Name PurCro Company Address 13 >�' � �, ) <br /> CA 9271880�` O v <br /> Contractor Spectrum ExploratiWdress15375 Barranca PktayJryigE1,,n r69 .7 4 753-1408 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n OEt of ervice Well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1K,LMonitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . ,;1 71N <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation In inrhpc Dia. of Well Casing A <br /> FI Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing PVC Specifications Se#-1i0 <br /> 1'1 Public CI Other Fl Delta Depth of Grout Seal R fppt Type of Grout re <br /> I I Irrigation 3-0-Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material b Depth o <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I I fNo septic system permitted if public sewer is <br /> available within 200 feet.) <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. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 6 Length of lines Total length/size <br /> FILTER BED C. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 /> 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 compensa- <br /> tion laws of California." <br /> The applican t call f It re ired inspections. Complete drawing on reverse side. t" <br /> Signe Title: Date: g <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �` / Area <br /> Pit or Grout Inspection by Date Final Inspection by Data�l <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health D <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUUES. AMOUNT RE/MINTED CASH K 11 RECEIVED BY DATE PER T NO. <br /> • EH 13211REV.I/AS) <br /> FH A-26 <br />