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f APPLICATION-FOR PERMIT . . �' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES1 YEAR FROM DATE ISSUED .fib q(Complete in.Tripiicate) + �. .f .. 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 J6aquin 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 San J0a'quin -County , ,-see map City Lot Size PM '�' 699 Hampshire Rd .--, 'Ste . 203 Owner's Name CGG Lani,d Seismic AddressWes tlak.e-Village, CA 9136-lPhone 805-496=4311 CGG Land' Seismi Contractor �ddress License No. Phone ` TYPE OF WELL/PUMP: I` NEW WELL ❑ WELL REPLACEMENT ❑ <t DESTRUCTION ❑ ! PUMP INSTALLATION ❑ SYSTEM 4REPAIR ❑ OTHER f<1 S h 0 t h O l e , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S;'bISPOSAL•'FCD. PROP. LINE ai FOUNDATION T AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ERCIBI EM AREA CONSTRUCTION SPECIFICATIONS ; Xl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation'a Dia. of Well Casing L1Domestic/Private ❑ Gravel Pack ❑ Tracy T.1 1ype of Casing Specifications ❑ Public Other Delta Depth of Grout Seal Type of Grout Q Irrigation, _ pprox. Depth '❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type'of Pump ' rr H.P. State Work Done Well Destruction C14 Well Diameter 50 n Sealing Material Itop 50'I I Depth Filler Material !Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is n ' available within 200 feet.) �'installation will serve: Resid once_ Commercial_ Other VCl Number of living units: �� Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ iN Method of Disposal Distance to nearest: - Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines a Total length/size S FILTER BED ❑ Distance to nearest: Well Foundation' 'Property Line SEEPAGE PITS ❑ Depth _ r Size Number SUMPS ❑ Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ Ip ,. r _ 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 Sari'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.' 11 The applicant mu call fo iI ired inspections. omplete drawing on reverse side. Signed X ( Title: Permit Agent 1-9- 86 Date: red OuseyO ARTMENT USE ONLY i Application Accepted by Date Area Pit or Grout Inspec n by Date -IP Final Inspection by LHtf,C 0-3Datey`Z�`' -- Additional Comments: ❑ Stk 466-6781 ❑ Lo 369-3621 . ❑ Man t 823-7104 -❑ Tracy 5 6385 Applicant- Return all copies to: Environmentai Health Permit/Services 1601 E. Hazelton Ave., P.O.FEE Box 2009, Stk."CA 9 052 1 � INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. + EH1324(REV.4 i a 5) �-5T �.�?- 4 £Sl gk, EH l o ' EH 14-26