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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA Telephone (209)466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Tripllcatel Appllce!lon 1$hereby made To the San Joaquin Local health District for a perms:to cvnsnurt and/or install the wofk herein described.Thh appuretlan Is made In compliance with Sen Joaquin County Ordinance No.50.9 for sewage or No.1962 for well/pump and the Ruled and Regulations of the Sen Joarluin Lcul Health Dlsrrict. Job Addrse$ _ 15120 F I N C K R p._ _ City TRACY_ Lot site____ -- _ PM _ I Owner's Name LISTER KROFIN _ ___ Addra$s _1.5424 –FINCKPMne - -�_2��-- Contractor'aName NN BROS.__DRIL.L. Llcen$cNn. _2908 __ _____. ph.. 81 _ 45,1185_ I TYPE OF ri'ELL/PUMP: NEW WELL [.I WELL REPLACEMENT EX� DESTRUCTION f_1 , SYSTEM REPAIR ❑ OTHER E3PUb1P INSTALLATION ff i' DISTANCE TV NEAREST: SEPTIC TANK __ _ SEWER LINES DISPOSAL fLD._-._ PROP.LINE t — FOUNDATION--_'—_AGRICULTURE WELL OTHEi1_WELL -- _ PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLE:�AREA CONSTRUCTION SPECIFICATIONS n !'. ❑Industrial Ll Open Bottorr iJ Manteca Dia.of Writ Excavation-_.. Ota.of Well Calling 1 s M DornestklPrKrete XKOravel Pack C(I Tracy Type of Casing.-.._---E 5pecllfcafiona Typa of Grout BINTO /l ❑Public C]Other IJ Delta Depth of Grout Seal _§.U- �Q� L'- 1 HENNI5 N O Irrigation _�1ppr0%. Depth 13 Eastern Surface Seal Installed byNGS- BR R_ 1` ---M•t-`I }: Ropolr Work Dona (-S Type M Pump „-_�_.___ HIP._ _ Staty Work Dona .---�-•- > Well Dour)=Ion ❑ Well Diameter --w _ Scaling hietelial(top So') ,.40-.�''✓ 1`'" ' Filial Material EBelow 60'I - yn D�'!-w� Depth-_ �L. — 'I TYPE OF SEPTIC WORK: Nf.W INSTALLATION U REPAIft1ADDtTION U DESTRUCTION 1_I iNo septic system permitted It public lower Is ` ava;lebla within 200 feet.! ' - Et Installation wm serve: Residence. Comma lelal-,,,__ j, Number'of living units: Number of bedroom$ Character of soft to a depth of 3 feel:- _._ _ -_ Water table depth r SEPTIC TANK ii Typal Mfg _ Capaclty No.Combe:mono -._ .�-_ - Method of bkpos81 �. S PKG.TREATMENT PLT:❑ Distance to nearest: WeSI u Foundaflon Property Lane -- -- -- ' LEACHING ONE ❑ No. &Length or lines _ Total length/arse r }; o Property LEr1e FILTER BED Cl Distance to rleemeet: _Weli_�- Foundation f� �. 5tEPA43E PITS ❑ Depth -Site Number r [ j SUMPS ❑ Dhrtence to naerast: Well Foundation - Property Line 3 DISPOSAL PONDS [] r I horehy txrtlfy that t have prepared this epp!icatioh and thatthe walk will be done In accordance with Sar.Joequln oounty ordina- slate laws,and ? tuba and roguiettons of the San Joaquin Local Health District. a I ' Hama owner M tleerlsed agent's sigiutture ceftlfkn the following:"I saltily that In the perforrn@nce of the work for which this p@rrtlit i!Irsu@d,t 1@E net IH-:,,I "Contmetor's Wing or sub-contr@cifiv Ngnstwe n' m neatbn taws of Ca a. g m wa rkma a co h1 web manner as to become xublecl Pa flaieon nse- Y►'tY con «rDto t to worklrl@n'a roe ii o nom eu _ i Issued- she a:' pa bloc r- i t!a work far which this permit $tea w Y � certifies tSx following; 'E certify that In the psrlcrma..,e o E , tion laws of COWOMIC j The appikant must call for all req rad inspm lops.Comdata drewln@,att reventa Irl!`�Q t- Slpr+ad C Daw7-22-91 F/ gfr�ARTMENT USE ONLY Data�C� "- Are@ . .a,pplkat;on Accepted by Date Final Inspection by. Date .0 Pk of Grout Inspattlon tfy I Addhlonal CoMirr !ta: ❑3tk 406 Ml ❑Lod 38& l CJ Ms " 623.7104 OT racy B3154M Applkam-Return @N copies to:Environ Health Permit/Sarvicos 1WI s.Hazelton Ave.,P.O. Box 2006,Stk..CA 86201 (TLA!/ : 1i/� /.�[�" F11- fF' .SrfJr� � -.; FSE AMOUNT tN1E AMOUNT REMITTED U►�3 REE:EIVEO BY DATE PlRMri'NO, ,`.. IK�O 1{� JC t d4' C' � 1 iF �•fJ I ��J dQ . IN lets urv.lavers 64.1� e , s S ' t k