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f=^ i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate? 12Q' Application is hereby made to the San Joaquin Local Health District 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 for sewage or No.181V for well/pump and the Rules and Regulations of the San Joaquin Local Health district. Job Address McDonald Island City, Holt Lot Size 885*-10 pM 375 N. Wiget Lane #130 Owner's Name Pacific Gas & Electric Address Walnut Creek, CA phon,(415) 943-7986 1 3400 Crow Canyon Road (415) Contractor PGandE Address. San Ramon, CA 94583 License No. 24101 Phone 820-2000 TYPE OF WELL/PUMP: NEW WELL Mpiezometwes�REPLACEMENT ❑ DESTRUCTION ❑ �r` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE iezometerP-5A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- LINE FOUNDATION 15001 AGRICULTURE WELL OTHER WELL 30' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS gas we ll ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation 12 Dia. of Well Casing 2rr 1" * Domestic/Private 91-Gravel Pack ❑Tracy Type of Casing. 2" PVC Specifications ❑.Public ❑ Other M Delta Depth of Grout Seal Type of Grout TyDe A N ❑ Irrigation --Approx.$Depth ❑ Eastern Surface Seal Installed by inter corn an ersonnel 9 Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter3 21r Sealing Material{top 501 Tyge_A Depth 26.51 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence._.... Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:1 Water table depth SEPTIC TANK ❑ Type/Mfg# Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal s Distance to nearest: Well Foundation Property Line } s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 Local Health District. Home owner or licensed agent's signature certifies the following:,"I oertify 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."Contractors hiring or sub-contracting 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 applicant must call f required inspectComplete drawing on reverse side. Sigma X Sr. Civil Engr. , DER Date: 6-26-86 10– 77 FOR DEPARTMENT USE ONLY 1 Application Acceptedby Data 1Area Pit or Grout Inspectio ' Date Final Inspection by Date Additional Comments: LJ ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63M Applicant-Return all copies to: Environmental Health Perink/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } - FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO fro ! +EH 19.24 IREV.1 /85) EH 1426 –��—