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APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 fk <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> -Complete in Triplicate) <br /> 12-1 <br /> 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 <br /> made in compliance,with San Joaquin County ordinance No.W for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> San Joaquin County, See map <br /> Job AddressCity Lot Size PM <br /> CGG Land Seismic t-99—Hampshire rd. Suite 203 805-496-4311 <br /> Owner's Name Address -Westlake Village,C-a. 91361 Phone -464-4574 <br /> CGG Land Seismic 209 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT 0 DESTRUCTION El <br /> PUMP INSTALLATION 71 SYSTEM REPAIR F-1 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES — DISPOSAL FLD.— PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL _ OTHER WELL PITS/SUMPS . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial 0 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private E3 Gravel Pack 0 Tracy Type of Casing--- Specifications lQ <br /> r. <br /> * Public ether N Delta Depth of Grout Seal Type of Grout <br /> * Irrigation --Approx. Depth - D Eastern Surface Seal Installed by— <br /> Repair Work Done E Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Dikimeter Sealing Material (top 501 <br /> Deplvtt Filler Material (Below 50'1 <br /> -7— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION 0 DESTRUCTION El Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units:— Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth— <br /> SEPTIC <br /> epth No. Compartments <br /> Capacity_ <br /> SEPTIC TANK 0 Type/Mfg <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> Disposal <br /> LEACHING LINE E No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation— Property Line SQ <br /> SEEPAGE PITS E Depth Size Number- <br /> SUMPS 0 Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS 0 county ordinances, state laws, and hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for a r uired . pections. Complete drawing on reverse side. <br /> Permit Agent June 1XIO 10,1986 <br /> Signed PEE &*11 Title: Date: — <br /> ti k <br /> rry 111on FOR TMENT USE ONLY <br /> ' ry 611'—Ii�F-Ar <br /> Application c ad by Date Area <br /> Pit or Grout Inspection by Date U /0-74-� Final Inspection by Date <br /> Additional Comments: <br /> L1 Stk 466-6781 U Lodi 369-3621 0 Mantecait/Services <br /> 0 Tracy 835-6385 95201 <br /> Applicant- Return all copies to: Environmental Health Permt/Services 160 H elton Ave., P.O. Box 20439, Stk., CAI – <br /> ;CE�" R4406K <br /> FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE t PERMIT 7NO. <br /> INFO <br /> + EH 13-24(REV.10/831 <br /> EH 14-28 <br /> t <br />