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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- (Complete in Triplicate) 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.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. z 2 �NZtLG(er [74ry ff Job Address McDonald Island City Holt Lot SL-e 885±10 PM 375 N. Wiget Lane #130 Owner's Name Pacific Gas & -Electric Address Walnut Creek, CA Phore(415)943-7986 3400 Crow Canyon Road (415) Contractor PGandE Address San Ramon, CA 94583 License No. 24101 phone 820-2000 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ® Piezometer P-6A s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 300 r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _12 Dia. of Well Casing 2" IN Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing 2" PVC _ Specifications ❑ Public ❑ Other M Delta Depth of Grout Seal 21-231 Type of Grout Type A ❑ Irrigation --4pprox..Depth ❑ Eastern Surface Seal Installed by inter companyersonnel N Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') _Type A { Depth filler Material{Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 3 available within 200 feet.) Installation will serve: Residence_ Commercial____:_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 4 Distance to nearest: Well Foundation Property Line , 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 tine . DISPOSAL PONDS ❑ r 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 certify that in the performance of the work for which this permit is issued, 1 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for uired in ions plete drawing on reverse side. Sr. Civil En r. , DER 6-26--86 ' 'Signed � Title: Date: FOR DEPARTMENT USE ONLY { Application Accepted by Date " , v + Area Pit or Grout Inspection byDate Fina! Inspection by Date ~g Additional Comments: ❑ Stk 466-8781 ❑ Lodi 3W-3621 ❑ Manteca M7104 ❑Tracy 83-6385 Applicant- Return all copies to: Environntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE' AMOUNT REMFrrED CASH RECEIVED BY DATE PERMIT'NO. ♦6M 112 (REV.1/85� i7U•W,�{I►, 3 S. d EH W25 t 5 � � ^7.2.%, z f