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0 APPLICATION 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address SPA At-t-arhmPntc City __ Lot Size/Acreage <br /> Owner's Name EBMUD Address 375 Eleventh ST,0akland,CAPhone(510) 287-1358 <br /> Contractor Pitcher DrillingAddress P 0. Box 50367 License No. 263085 Phone 25-8 10 <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION D Out of Service Well D <br /> PUMP INSTALLATION D SYSTEM REPAIR D OTHER X Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation 2 Dia. of Well Casing <br /> Cl Domestic/Private D Gravel Pack D Tracy Type of Casing-CA, $ li i t Si nnn Specifications <br /> I1 Public 14 Other Ll Delta Depth of Grout Seal 14Type of Grout Cement GTO t <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter 2 • 5�r Sea Sng Material i Dep Local SO 1 <br /> Depth 15 ' Fill r Material i p h ent Grout 14 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/A DITION I 1 DES R TION INo septic system perr9rtlled if public sewer is <br /> available within 200 la6t.I <br /> Installation will serve: Residence _ Commercial_ Othe /� 1 <br /> Number of living units: _ Number of bedrooms ((\\I v <br /> Character of soil to a depth of 3 leaf: Wat a -A 21epth <br /> SEPTIC TANK ❑ Type/Mfg apacity No. VVrnents <br /> PKG. TREATMENT PLT. ❑ Metho f Disposal <br /> Distance to nearest: Well Foundetio Pro rtV Line <br /> NX <br /> LEACHING LINE Ll No. d Length of lines Total I n9 ze <br /> FILTER BED ❑ Distance to nearest: Well u cation III <br /> rty line <br /> SEEPAGE PITS I I Depth Size N r <br /> SUMPS LI Distance to nearest: Well Found ion Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will bZnt.lation <br /> one in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I Certify Ihn the performance of the work for which this permit is issued, I shall not <br /> kmen's <br /> employ any person in such manner as to become subject to worcomp 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 applicant mfuuss/Y/call for all re ued inipections. Complete drawing on reverse side. /Y <br /> Signed X�/ O / ��'�.�./.li - �1. �_ Title: c �� ,,�1 /9 �Q�� 9ate: � � <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Page I3C <br /> EN 1324[REV.i i n 51 <br /> EH t420 <br />