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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 15120 F I N C K RD. City TRACY Lot Size PM <br /> owner'sNama LESTER KROHN Address 15120 FINCK RD . TRACY Phone 835-042 <br /> KENNINGS ' License No. <br /> BROS. DRILL 290813 Phone 545-11 <br /> Contractor's Name 85 <br /> TYPE OF WELL/PUMP: NEW WELL G WELL REPLACEMENT IN DESTRUCTION D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Bottou <br /> pie:of Well Casing <br /> industrial WOpen m ❑ Manteca Dia. of Well Excavation <br /> [I ❑ <br /> 0(I Domestic/Private )d(Gravel Pack 0 Tracy Type of Casing Specifications <br /> ❑ Other l Type of Grout <br /> ❑ Delta Depth of Grout Sea <br /> ❑ Public HENNINGS BROS . DRILLING -� <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> — <br /> Repair of Pum <br /> Repair Work Dons ❑ Typep H.P. State Work Done <br /> Well Dest9iction ❑ Well Diameter —, Sealing Material (top 501 <br /> x'70---9 L/ °f" Filler Material (Below 50') <br /> .sa E w j Depth �dza <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ availablleNo �wthine200 feet.)ied f public sewer is <br /> Installation will serve: Residence Commercial Other y <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation P rty <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> if <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line �F <br /> N <br /> SEEPAGE PITS Cl Depth Size umber <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and thgt the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Diistrict. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> me subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as 4o beco <br /> certifies the fallowing:"1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tlon laws of California." <br /> # The applicant must call for all required Inspections. Completedra in on reverse TLA <br /> a <br /> }, t't cyx-"-[ Dace: 7-22-9-1 <br /> Signed - <br /> F n ARTMENT USE ONLY <br /> Date 3-- Area <br /> k Application Accepted by <br /> 1Date Final Inspection by Date S Q <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3W3621 11 Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Envirvnmerpt:ai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> fly FrI <br /> L <br /> EE K R EIVED BY DATE PERMIT'NO. <br /> FO AMOUNT DUE AMOUNT REMITTED S <br /> i+EH 13-24 IREV.1018 <br /> 31 <br /> .EN W25 i <br />