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4. i > APPLICATION FOR PERMIT 61- 5'a un MiSn ? �. .* itoring Well Contractor ��r�t �. SAN JOAQUIN LOCAL HEALTH DISTRICT �� ;�`a`rid;-augers 'ngs to. be .. -�-_. e`r�or�ned by - 1601 E. HAZELTON AVE., STOCKTON, CA p ,+ Telephone (209) 466-6781 Hand riven Sampling Co. P.O. Box 1524 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED VAR 1X8$8 Antioch, CA 94509 (Complete in Triplicate) ! (415) 778-6000 FF�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h�hT described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin w Local Health District. -�+r"""�'�' �E fpm _,-• y Lflv._?3 j Job Address LINCOLN VILLAGE 'CENTER city STOCKY Lot Size PM LINCOLN PROPERTIES LTD 628 Lincoln Center,Stockton 415/478-9200 Owner's Name Address Phone Contractor �� ddress�T-"I_ 1 -��.t r License No.t � one �5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L7 DESTRUCTION ❑ PUMP INSTALLATION d SYSTEM REPAIR ❑ OTHER LM. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES See attaCheASPOSAL FLD. PaRQ'IP. 1NE- FOUNDATION AGRICULTURE WELLmap OTHER WELL a tPITS/S MPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc vation i Dia. of WJeH-Easing- r ❑ Domestic/Private 1 Gravel Pack ❑ Tracy � - Specifications f`l Public 17 Other ❑ Delta Depth of Grout Seal - Type of Grout neat cement I Irrigation - 5.Approx. Depth l 1 Eastern Surface Seal Installed by— e__ - •-� "' - Q Repair Work Done ❑ Type of Pump H.P. StateWak, Well Destruction El Well Diameter Sealing Material (top 50'1 _ �� ' T}� �1` f'F X .�j �. Depth Filler Material (Below 50'1 �v "� ;_vi`f - TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I 1 DESTRUCTION I I Mo septic4ystem permitted if public sewer is NA available within 200�feet,) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Ej%VlI;L.Vlt JAL HLALTH Character of soil to a depth of 3 feet: ater table depth SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal A Distance to nearest: Well Foundation Property Line I � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED NA ❑ Distance to nearest: Well Foundation Property Line I � e SEEPAGE PITS I'] Depth Size _ Number SUMPS -NA Ll 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 fallowing: "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 applicant ust for alZre ired inspe tions. Complete drawing on reverse side. Signed X �`� Tide: /�1 -�-� Date: FOR DEPARTMENT USE ONLY € Application Accepted by r Date / Area Pit or ro inspection by Date sJJ Final Inspection by Date t Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �y FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE A RMIT'NO. r INFO ��77^-�-�� +.EH 13-24 1REV.I/R 51 � J0 # v v_ [7 7r7 Eti;14-2t1 O