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APPLICATION FOR PERMIT - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION *REFER TO WORKPLAN 445PN0 AN JOAQUIN, PHONE 420 9520X , FOR DEPTHS AND SPECIFICATIONS ERMIT _R IRES 1. YEAR FROM DATE ISSUED (Complete in Triplicate) to in Application is s hhedrebynceAe,to San liance w uip County ith San Joaquifor roa pe Ordinance No�51+9ct aand e1862sand the tall eRules and vork eAegulationsof This rmit application 1 � Joaquin County Public Health Services. Job Address 18 4e • City Lot Size/Acreage East Bay municipal Utility District '" P _=_ Address 375 11th Street Oakland CA Phone 510 287-1663 Owner's Name _ Palo Contractor HEW Drillin Co. Address P-O- Bog 51182 Alto GALicense No604987 Phone415 322-2$51 *TYPE Of WELL/PUMP: NEW WELL E WELL RE CEMENT L7 DESTRUCTION ❑ Out of Service Kell OTHER ❑ Monitoring well pq PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � DISPOSAL MLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS *INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4rr Dia. of Well Casing Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Srh 40 _ C7 Dornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ PVC SpecificationsSch.40 n Delta Depth of Grout Seal Type of Grout Cement— I'1 Public V Other --� i I Irrigation w.Approx.iDepth I I Eastern Surface Seal Installed by HEW Drilling Co Bentonite Repair Work Done 0 Type of Pump H.P. State Work Dons Y well Destruction ❑ Well Diameter Sealing Material i Depth . Depth f Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l I (No septic system m permL)ed if public rawer is' available Installation will serve: Residence Commercial Other Number of firing units: Number of bedrooms Character of*OG to a depth of 3 feat:- Water table depth SEPTIC TANK. ❑ Type/MfB� Capacity No. Compartments : PKG. TREATMENT PLT.❑' � Method of Disposal Distance to nearest: Well .Foundation Property Line � f LEACHING LINE C1 No. m Length of linea Total length/sire _ FILTER BED Elce Distanto nearest: Wali Foundation Property line i SEEPAGE PITS 11 DepthSize Number 1 SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 fignatlirs certifies the to "I certify that in the performance rn the work for which this permf sub-contracting is t acting shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature r candies 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- tion laws of California." The applicant mustall for all rep wed inspections, late drawing on reverse side. Sig Title: x' Date: FOR DEPARTMENT USE ONLY DArea Application Accepted by at Pit or Grout Inspection by Date 9 ` Final Inspection by Date � Additional Comments: 'S , H*!#Z*3# # %� Applicant - Return all copies tOV San Joa in County Public Health Services � I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH R EIVED BY DATE PERMIT NO. INFO . EM 13•1411tEV.I/wai tUq 89.E 2 B-[ -93 3�1 EM 14.71