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j APPLICATION FOR PERMIT �` t SAN JOAQUIN LOCAL HEALTH DISTRICT � _ 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 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. Job Address FORWARD LANDFILL, S• AUSTIN RDi:ity STQCKTnN Lot Size PM Owner's Name GREG BASSO Address 9999 S AUSTIN RD Phone 209 ) 982-4298 Contractor WEST TEK DRI LL INGAddress 1363 VANDER WAY License No.,r n n 13 a Phone 408 297-6 7 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 2 0 0 ' + SEWER LINES 7 5 ' ± E DISPOSAL FLD. none PROP. LINE 2 5 ' FOUNDATION 100 ' E AGRICULTURE WELL none OTHER WELL ncnnP PITS/SUMPS NA_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private X Gravel Pack ❑ Tracy Type of Casing C- Specifications e1$ 1-1 Public 1❑ Other ❑ Delta Depth of Grout Seal ZD B1E L GfFidw��+G Type of Grout — I I Irrigation 110.Approx. Depth kEastern Surface Seal Installed by WESI af.K V91 _ Repair Work Done ❑ Type of Pump yoGH.P. State Work Done Well Destruction IX Well Diameter ��`s Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer i 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 l SEPTIC TANK ❑ Type/Mfg C No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Foundation Property Line LEACHING LINE ❑ �& oflines Total length/size FILTER BED ❑ est: Well Foundation Property Line SEEPAGE P I I Depth Size Number S Ll 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 signatu e 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 compens - tion laws of California." The applicant u call for 911 required ins tions. Complete drawing on reverse side. Signed X Title: DRILLING MANAGER`"' pate: 512(a/?l FOR DEPARTMENT USE ONLY Application Accepted by Date _V� Area ��.��-� Pit or Grout lnspectio Date Final Inspection by Date Additional Comments: ❑ 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 AMOUNT DUE AMOUNT REMITTEDH RECEIVED BY DATE PERMIT'NO. INFO EH13-24(REV.iin5) 0C ,� s�•—(i f1 .r�l� EH 14-26 PP