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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1'601 E. HAZEL T ON AVE., STOCKTON, CA # Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ! (Complete in Triplicate) rmit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local Health District for a pe or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. 1985DE. Flood Rd. , City Linden Lot Size PM Job Address 4 1985 F . Flood Rd. ,Li:nden Phone ` Owner's Name Larry LucChe ti Address ! 554 Purviance DrillersAApg P.o•Box 64,Linden License No. 377923 Phone 887-3 ! Contractor TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION ID J/�PUMP.INSTALLATION, SYSTEM REPAIR ❑ OTHER ❑DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESp15POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing❑ Industrial Open Bottom ❑ Manteca _ 'Dia. of Well Excavation ^- -_--_..__..�-,— „ XType of Casing Stee SpecificationstR Domestic/Private ❑ Gravel Pack ❑ Tracy 50 T e of GroutGeLl Public Cl Other ❑ Delta Depth ofGrout Seal ypi Irrigation .Approx. Depth l 1 Eastern' ." Surface Seal InstaNed byeW Wells neW Repair Work Done- .❑ Type of-Pump Sub H.P. 3 State Work Donees ___ _ Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l i DESTRUCTI N I I (Nilseptiwit stem emitted if public sewer is 1 200 feet I Installation will serve: Residence, Commercial_ th Number of living units: Number of bedro ms I Water tabl depth Character of soil to a depth of 3 feet: SEPTIC TANK ,� ❑.:f-TYPe/Mfg Capacity No. Com rtments PKG. TREATMENT PLT. ❑ Meth of Disposal Dist ce to ne est: Well Fo ndation —Pt y"Line I LEACHING-LINE ❑ No.T& engt of lines Total length/size FILTER BED ❑ Distanc to earest: Well Foundation Property Line SEEPAGE-PITS [ I Depth Size Number SUMPS Ll Distance t nearest: Well Foundation Property Line DISPOSAL PONDS ❑ that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I"have 7epared this application and k rules and regulations of the San Joaquin Local Health Di§trict. 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, l 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." l The applicant must call r all uired inspections. Complete-drawing on reverse side. 7/13/89 Signed X t wfi Title: Prt3S'ldent Date: - FOR DEPARTMENT USE ONLY ^� Date - Area Application Accepted by VA_r��_ y Date Date Final I spection� - Pit Or Grout Inspection by - ,f `�� Additional Comments: »❑-Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-6385 Applicant Return all copies to: Environmental Health PermitlServices 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH '+.EH 13-24(REV.r/H 5) EH 14-28