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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 $N� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1P � 1v '� 3 r', (Complete in Triplicate) 121 _ 1� � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her�yt q�sY41J This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an egulations of the:SagmAuin Local Health District.- 1°1� �Z-f,z-r �..�y� �Nv1�ONME�E�1G�5 McDonald Island ; v t I,�J Job Address __ City Lot Size fir` PM Owner's Name PG&E Address 3400 Crow Canyon Rd., San Ramon CA Phone (415) 866-:5877 Contractor All Terrain Address Roseville, CA (057) 437836 License No. Phone(916) 771-0222 TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)( MW 'G7 . DISTANCE TO NEAREST:. SEPTIC TANK 1000 ft SEWER LINES ------- DISPOSAL FLD. 1000ftpROP. LINE [= FOUNDATIONAfiRICULTURFr WELL 3000 ftQTHEA WELD 2000 ft PITS/SUMPS less than 50 -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial' - — ---r- 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 201/4" i ❑ Domestic/Private ❑ Gravel Pack r ❑ Tracy Type of Casing PVC Specifications ! i`1 Public f ther Wg to 1'0/20' p� M"I { Delta Depth of Grout Seal Type of Grout neat cement EI I Irrigation - 30'_Approx depth i I Eastern Surface Seal Installed by PG&E / All Terrain _ rw Repair Work Done ❑ Type of Pump none - H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 F Depth Filler Material (Below 501 I I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is 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 Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size `a FILTER BED { ❑ Distance to nearest: Well Foundation .Property Line I s SEEPAGE PITS 11 Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. t 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, I shall employ persons subject to workman's compensa- tion laws of Califor 'a." The applicant mus II for all re ire ons mplate drawing on reverse side. Signed X Title: 4 Date: /V 1,7 !SO FOR DEPARTMENT USE ONLY Application Accepted by t Date Vk 5 J Area -Pit oGrou Inspection by Date �z�i�� Final Inspection by Date @ �} l D Additional Comments: h--i3 Srj .❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 W''`� d t Applicant - Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i J FEEAMOUNT DUE AMOUNT REMITTED CIC RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 EH 14-=g(REV.1/n 5) 35.00 13s-—