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T. ` _ APPLICATION FOR PERMIT SAN JOAQUIN"L CAL HEALTH DISTRICT 1601 E.�HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6789 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. Job Address _Eight Mil-e. Road C;tyS t t7 C'k t O f ' Lot Size PM ` Owner's Name . Varies Address Phone CGG Land Seismic 699 Hampshire Rd. , Ste . 203 ContractorAddress Westlake . Vill . CA 9_lchrd.No, Phone 805-496-4.111 ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ K� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CX C S h 0 t h o E 5 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 '' 1 u ❑ Industrial ❑ Open Bottom` ❑ Manteca _ <:" Dia. of Well Excavatiori ' f c. JDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout :i ❑ Irrigation --Approx. Depth . .❑Eastern ,. Surface Seal•Installed by Repair Work Done ❑ Type of Pump * H.P. State Work Don R Well Destruction 13 Well Diameter Sealing Material (top 50') o a r s e':ti eno n i e y„ . n v 1 r 0 jJ U g (� Depth � i p Filler Material [below 50') TYPE OF SEPTIC WORK:, NEW INSTALLATION F) REPAIR/ADDITION r ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 _ '� available within 200 feet.) - Installation will ser ve: Residence Commercial_ Other Y Number of living units: Number of bedrooms A t', Character of soil to a depth of 3 feet: 'k Water table depth a i SEPTIC TANK ❑ Type/Mfg Capacity — m No. Compartments .. PKG. TREATMENT PLT. ❑ M W < ` . - Method of Disposal I j l..' .� Distance to nearest: Well t . >Foundation .Property.Line LEACHING LINE- ''_ ❑ -No. & Length of lines Total length/size. ,.x FILTER BED ❑ .Distance to nearest: Well Foundation. Property'Line f SEEPAGE PITS ❑ Size De Depth r'” p SUMPS 4� ❑ Distance to nearest: . Well Foundation v Property Line DISPOSAL PONDS ❑._,- , QI 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 agents signature certifies the following: "I certify#fiat 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 California." , . The applicant must call for all requ' d ins cti� s Complete drawing on reverse side. Signed -"Fredi Ouse Title: Permit Agent 7=19-85 Date. FOR DEPARTMENT USE ONLY Application Accepted by Date_ a r T _ Pit or Grout Inspection b e F nal'Impection " Date Additional Comme is ❑ Stk-466-6781 . ❑ Lodi, 369-3621 . ❑ Manteca 823-7104 ; ❑ Tracy93i-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Wil,) be bine' d $35/hr for inspection, � f A �. ..FEE tic AMOU AMOUNT REMITTED CK* RECEIVED BY CASH DATE PERMIT"NO. INFO' + EH 13-24 iREV.1/H 5) EH 1426 _ z w C • C�a°� �r,�N w Z'�-- 5 -D J"'g�tP {y i