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s> I APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE'LT ON AVE., STOCKTON, CA Telephone {209} 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) } 1090ication is ' Application is hereby made to the San,Joaquin Local Health District for a permit to construct and/or install the work herein describes of the ppl g}yJoaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and tt[e{'`!fVIR3RO,^tAti ��t Local Health District. , . APN 213 mnEd%710ES 21710 MacArthur Drive City T'r'acy Lot Size 1 .5 acre PM Job Address A dr ss 850 West March Ln. Stockton.- CAphone 209 943— Owner's Name Dennis Flynn 113 a A"CA ��c� Q r fl tcD'i ContractorBalbi & '&meg Associar ss 151 Link Road C'Whlia License NoCC 7/522125 Phone(70.7 864-20 0 TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER i�- !'�pr1i>�prrf/1� �I[i' ' II TO NEAREST..SEPTIC TANK NA SEWER LINES NA DISPOSAL FLD._NA PROP. LINE ii ...-DISTANCE f, FOUNDATION NA AGRICULTURE WELL NA OTHER WELL 2-9' PITS/SUMPS H INTENDED USE TYPE OFIWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 211 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ` r PVC Specifications X Domestic/Private El Gravel Pack �I Tracy Type of Casing �« f! 4 Type of Grout f' r'l Public ) Other 17 Delta Depth of Grout Seal t 1 Irrigation - 201-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 nn�� Depth rl Filler Material (Below 50') 1' TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is _ tt available within 200 feet.) "tel Installation will serve: Residence! Commercial.— Other I 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 1 r ..,SEPTIC TREATMENT PLT. L1Method o1 Disposal Distance to nearest: Well Foundation Property Line .I 1 LEACHING LINE CI No. & Length of lines Total length/size ffj FILTER BED ❑ Distance to nearest:' Well Foundation Property Line - ( � SEEPAGE PITS l I Depth $ Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C1 I il I hereby certify that I have prepared t its 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. j 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: '.l 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 Calif6 ntaP' The applicant must ca; If all equired inspections. Complete drawing on reverse side. Signed X Titre: President Date: 12/05/90 FO DEPA T USE ONLY Application AccepteRate Area d by /} Pit or Grout Inspection by Dat - �a Final Inspection by r— a�_ i - Additional Comments: _ Q 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 fFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 1 + EH13-24iREv.,/KSl _WipC^�"'� EH 14-2e '