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• APPLICATION FOR PERMIT • • A SAN JOAQUIN LOCAL HEALTH DISTRICT r • , 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (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. Job Address Forward Landfill S. Austin City Stnt-kf-nn Lot Size PM Owner's Name Greg Basso I Address 9999 S. Austin Road Phone - Contractor West Tek Drilling Address 1363 Vander Way License No. 500139 Phone( - 9 TYPE OF WELL/PUMP: NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 500'+ SEWER LINES 500'+ DISPOSAL FLD.NONE PROP. LINE 500' .$) FOUNDATION 500 + AGRICULTURE WELL NONE OTHER WELL NONE PITS/SUMPS ZA E �.50 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12" Dia. of Well Casing 4" ❑ Domestic/Private Xl Gravel Pack ❑ Tracy Type of Casing PVC Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal to be determinq*e of Grout bentonite _ N I I Irrigation 100.'Approx. Depth I I Eastern Surface Seal Installed by West Tek Drilling cement _ Repair Work Done ❑ Type of Pump NONE H.P. State Work Done_ Well Destruction ❑ Well Diameter 12" Sealing Material (top 50') .Water Quality Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No 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 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. s�'�� Signed X Title: Il :� Date: 1� A- ARTMENT USE ONLY , �+�7 Application Accepted by &�as kil �.�, 1 Date f is / rea Pit or Grout Inspection by Date Final b Inspection t-7`8 P Y i-�--_ ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi A4211 ❑ 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 CASH/1 RECEIVED BY DATE PERMIT'NO. EH 13-24+ EH 14-28(REV.r i n e)