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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 j 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. l�CCF{. Job Address o7Sisu�t /«/ T • - 177t0�r/p - — City Lot Size PM Owner's Name Frank Giannecehini Address P• 0. Box 10i Linden C phone Contraclo�'�iance Drillers Address_P• 0. 'Box 64 Linde rLicense No: 377923 Phone $ 7- 35 4 TYPE OF WELL/PUMP; --�_� MEW WELL �' WELL REPLACEMENT ❑ DESTRUCTION 3L r PUM"P'INSTALLATION'i�` SYSTEM REPAIR ❑ DISTANCE TO NEAREST: Sr_PTIC TAMC t OTHER D SEWER LINES DISPOSAL FLD. PROP- LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �I ❑ Industrial 16—open Bottom ~~ - ❑ Manteca Dia. of Well Excavation 0 Domestic/Private ❑ Gravel Pack rr -Dia. of Well Casing FJ Tracy Type of Casing StPp1 i �r1 M Public (� Other Cl pelta Specifications � Depth of Grout Seal Type'of Grout xpQrrigation 4.25.Approx. Depth 1 1 Eastern O Repair Work Done L3 Type of Pump Surface Seal Installed by Weft Destruction e H.P.❑ Welt Diameter � HP State Work Done pul ' Sealing Material (top 50'►Old atmPL M-La a3 i' i n nr��* Depth Filler Material l8elow 50'1 WPB 1 = TYPE OF SEPTIC WORK: NEW 1NSTALLATlON I 1 REPAIRIADDIT{ON.I ' DESTRUCTION I ) IN septic system S' r►available within 200 feet�t'ed if-public sewer is � Installation will serve: Resilience� •Commercial.� Other � � ' Number of living units: Number of bedrooms Q;i Character of soil to a depth of 34'eet: SEPTIC TANK CD Mfg "'""— `�" _ Water.table depth III PKG. TREATMENT PLT.D Capacity _ _f No. Compartments Distance to nearest: Well Foundation Method of Disposal Property Line 1 LEACHING LINE ❑ No. & Length of lines FILTER'BED ` Total length/size ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth Size { ! SUMPSNumber i Ll Distance to nearest: Well" FoundationProf DISPOSAL PONDS ❑ perty Line I 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 i I rules and regulations of the Sen Joaquin Local Health D��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, 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:"{certify that.in the performance of the work for which this per tion laws of California." mit is issued, I shall employ persons subject to workman's compensa- - The applicant must call for all required inspections. Complete drawing on reverse side. Signed X ��- � Presdient '' Title: Date:10/31 8 8 FOR EPARTiIAENT USE ONLY • Application Accepted by �l iv��' _•��.�'—T!{} Q � �� Y� _ � 1 it Date Area Pit or Grout Inspection by Date _ Final In coon by to Additional Comments: ` ❑ Stk466-6781 ❑ Lodi 369-3621 A ❑ Mant a 823-7104 ❑ cY 6385 Applicant- Return all ca : em rfb) ,ntei Healthm,Vtit4,Servic 4y% 0 Haze e�-1?q� 0�2 CA 9520f ..,� FEE Oct vin,' ��ll INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIT"ND. H 13.24 IREV.s H 51 �f O� � I H tL28 � 1133