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APPLICATION is SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Joaquin County Public Health Services. Job Address See Attachments City Lot Size/Acreage Owner's Name EBMUD Address 375 Eleventh ST.Oakland.CFQhone1297-1 35 Contractor Pitcher Drilling Address P.O. Box 50367 License No. 263085 Phone — 910 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYS REPAIR OTHER $K Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULT E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION S ECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tion r' Dia. of Well Casing f_7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ S 11 S OOri Specifications I"1 Public X7 Other n Delta Dept of Grout sal 14 ' / Type of Grout Cement GYO t I I Irrigation _Appro . Depth I I Eastern SuAac Soul I tailed by Repair Work Done ❑ Typa of Pu p H.P. to Work Done_ Well Destruction ❑ Well Diam at 2 . S rr Sealing terial epth Oca Depth r Filler --trial i th t TYPE OF SEPTIC WORK: NEW INWALLATINI ) AIR/ADDITIO I DEST CTION I ( t system permitted itpublic sewer is ithin 200 feet.lInstallation will serve: Residence her Number of living units: NCharacter of&oil to a dept of 3 fWater table depth SEPTIC TANK ❑ / Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Dist l oundation Property Line LEACHING LINE ❑ No. i Lgth of lines Total length/size FILTER BED ❑ Distance t n rest: Well Founds Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nes t: Well Foun tion Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this applicati and t at 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 t f lowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become sub' t to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performanc of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion [am of California." The appl�ualiall recur d insp tions. Complete drawing on reverse side. C @ PCf�/t— �Aate: Signod Title: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments, Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7N0. EH Y2a MEW.vxsi Page 13B EH;4'.n I i