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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 p (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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job Address o TS � AW-11-IJ ._ _7 /-77:-- ut0-10 City Lot Size PM I Owner's Name Frank Giannecch.ini Address P. 0. Bax i0 Linden C T� Phone Contractor urvianCe Drillers Address �'• O. ?Box 64 Linde TYPE OF WELL/PUMP: license No. 37]__ 923_Phone_ 887- 35rjL� EW WELL ]�' WELL REPLACEMENT ❑ PUMP;'INSTALLATIONDESTRUCTION"X' SYSTEM REPAIR ❑ ML DISTANCE TO NEAREST: SEPTIC TANK -JOTHER ❑ SEWER LINES — DISPOSAL DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ~� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man-� teca Dia. of Well Excavation rr -Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T � {th * Public Type of Casing t 1 Specifications i1 Other Cl Delta Depth of Grout Seal IMtrigation 4�.Approx. Depth I 1 Eastern TYPe of Grout Repair Work Done ❑ Type of Pump turbine H.P. HP al Installed by r1' Well Destruction ❑ Well Diameter SState Work Dane �� pul Sealing Material {top 50'10? Depth Filler Material I8elow 5011 aba Ill17 TYPE OF SEPFIC WORK: NEW INSTALL4TION I I REPAIR/ADDITION.I 1 DESTRUCTION I 1 No septic system I > r permitted of-public sewer is Installation will serve: Resilience Commercial available within 200 feet.) . Commercial— Other Number of living units: Number of bedrooms Q.i Character of soil to a depth of 3'feet: SEPTIC TANK "" -� — Water table depth ❑ �TypelMfg PKG. TREATMENT PL-T. ❑ Capacity I No. Compartments - �„✓'� Distance to nearest: Well Foundation PropertMethod of Disposal y Line LEACHING LINE Q No. & Length of lines - FTotal length/size ILTER'BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size I Number SUMPS i Cl Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line { 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 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 applicantmustmust call for all required inspections. Complete drawing on reverse side. k Signed X�`-e 41 Title: Presdient Date:10/31/8 8 FOR EPARTiMENT USE ONLY Application Accepted by CS _ 1 q Date Area Pit or Grout Inspection by Date Final Inspction by to Additional Comments: `. - 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mont ca 823-7104O Applicant- Return all co torp�j ental Health rmht,Servic 1 ❑ cy a�5 Be 009, CA 95201 Haze FEE AMOUNT DUE AMOUNT REMITTED CKPERMIT ND. INFO CASH RECEIVED BY DATE y t� «.EH 13-21(REV. /H5) -(-)2 r-H 14-28 �sS�-9®Q