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APPLICATION FOR PERMIT We SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 'f'YEAR FROM DATE ISSUED 7 6250 � , S��„j c�S�� 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. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. New Hope Tract/Canal Ranch/Staten Island as per attached map. Job Address City Lot Size PM _ Two (2) geophysical survey lines across various properties. Owner's NamePerMi ssiori obtained franssall OWners and _lessees. Phone Western Geophysical Company (805) 325 4014 ContractorP @ O* BOX 3179 Bakens Afield: Ca. 93302 License No. N/A Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ XKxXxmxx(1I3ophysicaJ. WeJL.Ls PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER70X 50 feet deep 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 Approx. 248 holes ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Bentonite l Public ❑ Other fl peltaDepth of Grout Seal Type of Grout Cone• I Irrigation --Approx. Depth I 1 Eastern Surface Seal installed by Western Geo ph sical Repair Work Done ❑ Type of Pump H,P. State Work Done `A Well Destruction ❑ Well Diameter Sealing Material (top 50')Sealed to 4 feet below surface •3 Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK; NEW INSTALLATION I1 REPAIR/ADOITION I I DESTRUCTION I I iNo 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 c.r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 I I 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 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 musW for all required inspections. Complete drawing on reverse side. Signed X f Title: Permit Agent Date: 4-_13-89 R. E. Buic F01i EPARTMENT USE ONLY Application Accepted by Date Area /0 / Pit rou Inspection by bate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 Tracy 835-&95 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, 4.EH13.24IREV.i/n5) -73 EH 14-28 t7