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tea _ 1 q , 3D APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON,'CA Telephone (209) 466-6781 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ( 2- 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 w6upump and the Rules and Regulations of the San Joaquin Local Health District. RAla McDonald Island PG & E Compressor �i�ia_ ion Lot Size 3 acres pM Joh Address PG & E PO Box 250 Antioch, CA. A4509 415 757 1701 Address Address2.2 3,54City TYPE OF WELL/PUMP: NEW-WEEL:. WEL-L;REPEXCEN1t_N-1� " puce i nv�,I X ! ! PUMP INSTALLATION ? SYSTE IR ❑ 4TR ❑ 10DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL l LD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr a )p Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1�-.-5 /R" Dia. of Well Casing r--�_ ❑ Domestic/Private XCR Gravel Pack ❑ Tracy Type of Casing PVC' Specifications SCC 40 N Fj Delta Depth of Grout Seal 0 r - Type of Grout__9___s � .--_—, ^ f� Public Other r; I I i Irrigation --Approx. Depth 4 I Eastern Surface Seal Installed by H p State Work Done _�.=*+a.11 I -� Repair Work Done ❑ Type of Pump �— 9 S ` Well Destruction Well Diameter 3n Sealing Material (top 50'1 f Depth +60 ' Filler Material (Below 501 same INSTALLATION 1:1 REPAIRIADDITION l I DESTRUCTION I ) INo septic system permitted it public sewer is TYPE OF SEPTIC WORK: NEW INS available within 200 feet.) 4 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 171 Type/Mfg Capacity No. Compartments r iMethod of Disposal PKG. TREATMENT PLT. ❑ � Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED llDistance to nearest: Well Foundation Property Line Y I SEEPAGE PITS l I Depth Size Number r SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I 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, 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 he performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Califo ia." ' The applicant call f I r uire ins i mplete drawing on reverse side. Signed X . Title: VP Clark Date: 1 Sept 88', k FDEPARTMENT USE ONLY Application Accepted bykjrL, Date Area Pit or Grout Inspection by7 �� Date r. -1'�; Final Inspection by — DateAdditional CommentQR ❑ Stk 466-6781 Lodi 369-3621 O Manteca 823-7104 ❑ racy 835-6385 � ` N. Additional Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.. C' A 95201 /.w_?,_� tiAIL FEE AMOUNT DUE AMO T REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO 0,� �_ fC/o, --cam �,� �' S 9��a a +.EH t3-24 1pEV.1 i n 51 �V EH 14-29 't