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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA `� Telephone (208) 466-6781 PERMIT EXPIRES 1 YEAR 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 meds 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 Q Austin Rd, City Stockton Lot Size PM — Owner's Name Greg Basso Address °O°o c Austin Rd - Stark on Phone — 982-4298 4) �Lo 0, 2789 Liberty Ln. 437836 - - Contractor All Terrain nril7 _ Address Rosevi11e,CA License No X57 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ZX monitoring well DISTANCE TO NEAREST: SEPTIC TANK ?(1(ir+ SEWER LINES75r�_ DISPOSAL FLD. nnnb PROP. LINE _251 FOUNDATION L00r 12 AGRICULTURE WELL -none- OTHER WELL jaaji. PITS/SUMPS �A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS wire warp FsG;T@�[I O Industrial ❑ Open Bottom O Manteca Die. of Well Excavation 12 Dia.of Well Casing n O Domestic/Private 12 Gravel Pack O Tracy Type of Casing PVC Specifications O Public O Other ❑ Delta Depth of Grout Seal to be determ. Type of Grout cement O Irrigation ]4)oApprox. Depth Q Eastern, Surface Seal Installed by Al I Terrain Drillin2 Repair Work Done O Type of Pump _"Gine H.P. State Work Done Well Destruction O Well Diameter 12" Sealing Material(top 501 Water Quality Depth Filler Mate"(Below 60') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer is available within 200 feet.) Installation will Residence_ Commercial_ 0 Number of Irving units: Number of bedrooms Character of soil to a depth feet: Water table depth SEPTIC TANK ❑ Type/ Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to rest: —Well Foundation Property Line LEACHING LINE ONo. ngth of lines Total length/size FILTER BED O nce to nearest: Well NU Foundation Property Line SEEPAGE PITS 16 Depth Size Number SUMPS O 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must for all required inspections. Complete drawing on reverse side. Signed Title: Engineering Geologist Date: �4t FOR DEPARTMENT USE ONLY �„ _ � \9 Application Accepted byDate Arear - n Pit or Grout Inspection by Date Final I n Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3&9.3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Retum'all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO 35 c �� .r F t f- i EH 1124(REV.iie5) _ EH 14-26