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APPLICATION FOR PERMIT 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 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 Rd. City Stockton Lot Size PM Owner's Name Greg Basso Address 9999 S. Austin Rd. Stockton Phone 209-982-42 437836 2789 Liberty Ln. Rosev�;le�e No. C57 Phone 916-771— 22 WELL REPLACEMENT ❑ DESTRUCTION ❑ OTHER�monitorin well Contractor All Terrain Drillin%ddress TYPE OF WELL/PUMP: NEW WELL ❑ K PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ g DISTANCE TO NEAREST: SEPTIC TANK 200' -i- SEWER LINES 75' + DISPOSAL FLO. none PROP. LINE 251 PERMIT NO. FOUNDATION 100' E AGRICULTURE WELL none OTHER WELL none PITS/SUMPS -W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS wire wrap screen ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 411 PVC ❑ Domestic/ Private ® Gravel Pack ❑ Tracy Type of Casing PVC Specifications bentonite ❑ Public ❑ Other ❑ Delta Depth of Grout Seal to be determ. Type of Grout cement ❑ Irrigation l 00Approx. Depth ❑ Eastern Surface Seal Installed by All Terrain Drilling Repair Work Done ❑ Type of Pump none H.P. State Work Done Well Destruction ❑ Well Diameter 1211 Sealing Material (top 50') Water Quality Depth Filler Material (Below 50'► TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation w�ile: Residence _ Commercial _ 0 erNumber of ing urn Number of bedrooms Character of soil to a dept 3 feet: Water table depth SEPTIC TANK ❑ Type Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to res . Well Foundation Property Line LEACHING LINE ❑ No. ength of lines Total length/size FILTER BED ❑ tance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ 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 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." I The applicant m all for all required inspections. Complete drawing on reverse side: Signed .� - Title: Engineering Geologist Date: L FOR DEPARTMENT USE ONLY Application Accepted Date S -16-8n Area o Pit or Grout Inspection By ---Date Final Inspection by Additional Comments: (��lJh„ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e + EH 13.24 (REV. 1/ e 5 EH 14-26 Date FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. W