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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1�1 I a ; ;';,714; Telephone (209) 466-6781 , 1 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) ' X390 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 tlfq^ I� gaR�,f3ogl}l�t(ions of the San Joaquin Local Health District. APN 213-F z�WlEv V10ES L� 21710 MacArthur Drive Tracy 1 .5 acre Job Address City Lot Size PM Owner's Name Dennis Flynn Agdrrss 850 West March Ln. Stockton, CAPhone 20 943-6408 13a�c 'A <A 6x-r O�� t to., Balbi & Chang Associi ,VSs 151 Link Road, Can�tia License No�57/522125 Phone 707 864-20 0 TYPE OF WELL/PUMP: NEW WELP9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER B- rV1(QAi)().-.It (.Melt DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES NA DISPOSAL FLD. NA— PROP. LINE 11 FOUNDATION NA AGRICULTURE WELL NA OTHER WELL 25 t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C3Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing 2" * Domestic/Private ❑ Gravel Pack 1C Tracy Type of Casing PVC Specifications ('1 Public X1 Other F1 Delta Depth of Grout Seal 4 Type of Grout r I I Irrigation 20.Approx. Depth l I Eastern Surf V t Iraterk _ Repair Work Done ❑ Type of Pump H.P. ne Well Destruction ❑ Well Diameter Sealing Maters op 1 Depth Filler Material (Below 50') �J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Q Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal n Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line S` SEEPAGE PITS I 1 Depth Size Number \ SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 Calif n The applicant must ca f all equired inspections. Complete drawing on reverse side. Signed x Title: President Date: 12/05/90 FO DEPA T USE ONLY Application Accepted by Date 2-11 7AgArea Pit or Grout Inspection by Datp� ga Final Inspection by atbe Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-2 (REV,t i x sl Q0 (� EH 1M28 —1 �J