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Post-it"*Note 7671 #ot Date pages To From !h ES J4421 Co./Dept. Co. Phone# Phone# Fa 3() \Z�15 Fax# ) Application is hereby made to Sm 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 Attachmentsy/r"^ 7�AY><r}� Cary Lot Size/Acreage C3(�3-off—Ih �I VE OFtr- iLt� Owner's Name EBMUD Address 375 Eleventh ST Oakl anrir(`A Phone Contractor Pitcher Dril l i na Address P.O.Box 50367License No. 763085 phone 1C TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT D DESTRUCTION:PRO:P. of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR C OTHERMonitoring Well C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINEFOUNDATION AGRICULTURE WELL OTHER WELL UMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of We Excavation 2" Dia. of Well Casing D Domestic/Private D Gravel Pack ❑ Tracy Ty of Casl q"_CA SDI it" Snnnn Specifications I'1 Public Other 11 D to Dept of Gr ut Seal ' Type of Grout Cement GTO t I Irrigation _Approx. Depth E tern Surface Sea Installed y Repair Work Done U Type of Pump H P, State Work Done_ Well Destruction ❑ Well Diameter " Se ng erial Dept T.nna 1 gni 1 1 I Depth I Fil r ter 1 c Dept Cement Croat 1 4 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I EPAIR/A IT] N i I DEST UCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: _ Number of rooms Character of soil to a depth of 3 feet: a er ladle C a meth SEPTIC TANK ❑ Type/Mfg Ca acity nta PKG. TREATMENT PLT. C M t Disposal Distance to nearest: Wel Found tion Pr party LEACHING LINE n No. & Length of lines Total I ngth/size FILTER BED C Distance to nearest: Well Fou nation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well F undation Property Line DISPOSAL PONDS C 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 signature certifies the following: "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 subject to workman's compensation laws of California." Contractor's hiring of subcontracting signature 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- tion laws of California." The applifor all req uir inspgcti s. C plate drawing on reverse side. Signed X Title: Y^ C(� Date: - ��/ O,ffl�tA, FOR DEPARTMENT U E ONLY Application Accepted by �CC)I" V'y''-� Date J2- Area Pit or Grout Inspection by Oats 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. EX 1 3-24 IREV.rix Sl Page I3A ER ,..2a 1o�f�� 2311jV r �i �3h�