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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _ PERMIT EXPIRES YYEAR`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 Ryles and Regulations of the San Joaquin Local Health Districts Job Address E i g h t Mile R O a-d City S to c k� _6n Lot Size PM Owner's Name Varies Address - - Phone CGG Land Seismic 699 Hampshire Rd . , Ste 203 Contractor Address Westlake V i l l . , C A. 91 arm No. Phone - 11 TYPE OF WELL/PUMP: NEW WELL ❑" WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER d( S h O t h o l e s 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 ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f ❑ Public Cl Other ❑ Delta aDepth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter 4" Sealing Material (top 501 if / Depth . 5 n ' _ Filler Material (Below 50' �C_a_a_r_-S e R P n t o n i t.e , E n v i r nPLu g f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if 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 JT i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments / PKG. TREATMENT PLT. ❑ Method of Disposal w 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 r ❑ 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 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 subcontracting 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 req ' d in C' Complete gpawting on reverse side. Signed X E r e d 0 11 s im y Title: Permit Agent Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 7 - ! A a Pit or Grout Inspection by Date Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy SK6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201 Will be billed $35 /hr for -inspection. - FE inspection, - 7 INFO AMOUN AMOUNT REMITTED CASH RECEIVED BY � SDA�TE (PERMIT'NO. + EH13-24IREV..1/85) f "�',^�� b - �� (�1�'" d.>"UAI EH 1426 C