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1,101�-- . r APPLICATION'FOR PERMIT ' SAN J4AQtlK LOCAL ;�lrA .TH DISTRICT , ` > 1601 ET HAZELTON AVE., STOClCTON. CA � Telephorlb ',109) -6781 (Complete In Triplicate) PERM„T%� 'r',;� STN Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descritaed'.'T'tiis application,is made in compliance with San Joaquin County Ordinance No. 549 for sewage or Nd. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Y n Job Address 6425 Pacific Ave and UxVlas road Cit SLock Lot Size 13 , X 1613, . PM I _ Owner's Name Regal—A yacklarl Cd-1 �y Address 1765 0)aUerlige Way Phone . (916} 921-1100 _ sa==me ttn, CA 9p581 SNI+ i LIXIMIs Contractor Address_ 3Z2 Y' icense No. Phone 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION Ca SYSTEM REPAIR C7 OTHER 3 TBst BnriM DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE T FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial FJ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing _ D Domestic I Private L7 Gravel Pack L71 Tracy Type of Casing Specifications M Public 1-1 Other 14 Delta Depth of Grout Seat Type of Grout Neat Ott__ i I Irrigation ±50'-Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material (top 501 Neat .fit; Depth Filler Material (Below 501 1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system parmitted if public sewer is �1 available within 200 feet.) Installation will serve: Residence_ Commercial-- Other Number o1 living units: Number of bedrooms_ Character of soil to a depth of 3 feet: _ _ Water table depth 77) SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1% PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No, & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well. Foundation Property Line SEEPAGE PITS 1l Depth Sue Number SUMPS L I Distance to nearest: Well. Foundation Property Line DISPOSAL PONDS n 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: "1 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 airing 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 California." The applican=Mall for ail r ad inspections. Complete drawing on reverse side. ,° �•/�.A Signed Title: Data: ,� !�T FOR DEPARTMENT USE ONLY Application Accepted by Date Area > r L Pit or Grout Inspection by �� Date,/ Final Inspection by Date 1✓ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 D Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY GATE P£RMIT'NO. INFO J`� / �`�"/� G,01/ r.EH 1324 IREV.r i s J –/Gj /a— /y� ,01 Z 7l EH 14-26 ✓✓✓ r ! [ El' LP3 J