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E : APPLICATION OR PERMIT , SAN JOAQUIN LOC : HEALTH DISTRICT } r 1601 E. FfAZELTON �'E., 70 TON, CA Telephone { r)91 466 6781 PERMIT EXPIRES 1 YE 4 IR FROM DATE ISSUED u - (Complete !'Triplicate) Application is hereby made to the San Joaquin Local Health District for a p, rYrit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewag rr No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. {; Job Address 3rd & McCarther Trnrt #9 77 city _Tracy Lot Size PM Kaufman & Broad 63791! 'Clark Avenue Dublin 415-829-4500 Owner's Name Address Phone Contractor Glenn Marfell & Son Address 1818 Love Idge Road, Ptd§�% 51.0952 Phone415-432-428 TYPE OF WELL/PUMP: NEW WELL ❑ WELL PLACEMENT © DESTRUCTION PUMP INSTALLATION ❑ S TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ! DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE DELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CO ;TRUCTION SPECIFICATIONS ❑ Industrial D.Open Bottom ❑ Manteca Dia• if Well Excavation Dia. of Well Casing I Domestic/Private 11 Gravel Pack Ll Tracy Ty df Casing Specifications n Public C1 Other D Delta De ihcf Grout Seal Type of Grout t I� I I Irrigation _.Appfox, Depth l I Eastern Su ce Seal Installed by s Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction Well Diameter 7rr Sealing Mate I IlI.top 50') neat Cement ' k Depth —-- 391 Filler Material Blow 501 neat cement t= a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIO [[I DESTRUCTION l I (No septic system permitted if public sewer is �I available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: �I Water table depth SEPTIC TANK ❑ Type/Mfg _t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ndation Property Line i6 t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well uindation Property Line SEEPAGE PITS ! I Depth Size Number SUMPS L1 Distance to nearest: Well undation Property Line DISPOSAL PONDS ❑_ f I hereby certify that I have prepared this application and that the work will a done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. If Home owner or licensed agent's signature certifies the following: "I certify' at 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 co 99sation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whiff this permit is issued, I shall employ persons subject to workman's compensa-b tion laws of California." ;I The applicant must call for all re ired inspections. Complate drawing on erse side. I �4 Signed X Title: P resident Date: 4/5/89 FOR DEP T ENT USE ONLY e Application Accepted by Date �` Area Pit oreGrout Inspection by Date Final,Inspection by Date Additional Comments: Il ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1 E€. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 I: FEEa INFO AMOUNT DUE AMOUNT REMITTED '; RECEIVED BY DATE PERMIT'NO. �I +.EH 13-21(REV.t/N st � 11 r EH 14-29 � � 1 Li/