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( j APPLICATION FOR PERMIT r SAN JOAQUI.N LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE., STOCKTON, CA s Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED C- b, ,�/3DAJ2--;Q-} I (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. Y San Joaquin.County, "see map' Job Address City Lot Size PM 699 Hampshire Rd., Ste 203 CGG. Land .Seismic: Westlake Village,"Owner's Name � Address � ," CA 91361 Phone (209) 794--2382 CGG Land Seismic _•� Contractor - Address_ !"u"N� /�6�(_License No. e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O�PROP. DISTANCE TONEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. E _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS k Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 31 � r El Public - IQ Other T± Delta Depth of Grout Seal Type of Grout ❑ Irrigation 50 Depth ❑ Eastern Surface Seal Installed by ~ t Repair Work Done ❑ Type of PumpOrr H.P. :State Work Done Q Well Destruction FJ Well Diameter Sealing Material (top'50') yoarse Bentonite Clay Depth 50', Filler Material {Below 50'.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 * NA available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: I Water table depth 1 SEPTIC TANK ❑ Type/Mfg:[ Capacity No. Compartments PKC. TREATMENT PLT LlMethod of Disposal ' Distance to nearest: Well,- Foundation Property Line r � LEACHING LINE ❑ No.'& Len th of lines Total length/size f I i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS s .❑ Distance to-nearest: Well Foundation Property Line JD DISPOSAL PONDS ❑ _ I I \ j 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 j rules and regulations of the San JoaquiAocal 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 'ti Ci 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 ree dinin inspections. Complete drawing on reverse side. Signed X �W?r! Permit Agent 6-16-87 i li Title: Date: Michael Riordan FOR DEPARTMENT USE ONLY Application Accepted by Data �/ – A ` ` Ar a7 Pit or Grout Inspection by Date Final Inspection by oei 4 pate Additional Comments: r = ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE. - AMOUNT REMITTED GASH RECEIVED�3Y DATEaPERMIT'NO. S p asEH 13.24'REV.5/H 51 l.� � r� /EH 14-28C.J