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• APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. ��,M� Job Address See Attachments ��1 A •w'"' Ciry Lot Size/Acreage cos-010-172} Owner's Name EBMUD Address 37S 71 Pvpn h ST,Oakl and ,CA Phone - Contractor PltCher DTlllina Address P.O.Box 50367 License No. 263085 Phone 10 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 2" Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Cas; ('.A C1l i. t Soon Specifications I'I Public fm Other 11 Delta Depth of G ut Sea ' Type of Grout Cement Gro t I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed b Repair Work Done IJ Type of Pump H.P. S to Work Done_ Well Destruction ❑ Well Diameter 2 _ S" Sealing Mater 1 a Be th ' Depth 5 ' Filler MaterialDepth 1 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAI /ADDITION D TRUCTI N I I IN septic system permitted it public sewer is a in., within 200 feet.l Installation will serve: Residence_ Commercial_ 0 her Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: Water bb depth SEPTIC TANK ❑ Type/Mfg Ca ity No. Com artments PKG. TREATMENT PLT. ❑ Me f [lisp Distance to nearest: Well Foundation Proper& y Lip LEACHING LINE ❑ No. g Length of lines Total pang, siz FILTER BED ❑ Distance to nearest: Well undation Prop try Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundati n Property Line DISPOSAL PONDS ❑ 1 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 or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applica for all req uir Q inspecti s. C mplate drawing on reverse side. Signed �J Title: yl Date: FOR DEPARTMENT U E ONLY Application Accepted by Date 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 /AMOUNTDUE AMOUNT�ITTED pCASH RECEIVED BY r�.D1ATTEE /PERMIT NO. Page IJA . EH Iz-14IREV.irnmi vf/t 10�1 /� �,-//, IGJI /� V10 EH 13.21 � 1 r/1/�(/ l