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Vo 1 4 APPLICATION FOR PERMIT � G SAN JOAQUIN LOCAL HEALTH DISTRICT-- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED —Y� - {Complete in Triplicate) �/,po_c)Z,0 _ ..��.> .aLt`Dom_..:._.. 09" -�fr<f�73 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 i 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 Local Health District. LINCOLN VILLAGE CENTER City Lot Lot size PM Job Address LINCOLN PROPERTIES LTD 628 Lincoln Center, S ockt pnon415/478-9200 Owner's Name Address P. 0. Bax 1109 r Contractor P C EXPLORATION, I"I�EAddressRoseville, CA 95661 Licenser 7"265556 Ph9n6/783- 9733 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEMRtE�AIRh❑ OTHER CX groundwater mon? ori DISTANCE TO NEAREST: SEPTIC TANKSee a aG e . SEWER LINES _ SPOSAL FI-D.— PROP..LINE S>ee attache map: FOUNDATION AGRICULTURE WELL --. OTHER WELIse attarpkOsUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 1/2" ❑ Domestic/Private EX Grave) Pack ❑ Tracy Type of Casing PVC schedule 40 Specifications � F`1 Public F1 Other C-1 Delta Depth of Grout Seal + 45 Type of Grout neat cement 4 I I Irrigation 65--..Approx. Depth l I Eastern Surface Seal Installed by tremi a method (� Repair Work Done ❑ Type of Pump H.P. State Work Done— L' Well Destruction ❑ Well Diameter Sealing Material (top 501 X Monitoring Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION t I (No septic system permitted if public sewer is I N/A available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ;= 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 t j PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line v LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED N/A ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I l Depth Size Number SUMPS / ❑ 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 California." ! The applicant Fust c II for all required inspections. C iplate drawing on reverse side. .�,� w Signed X h -G 1�fAt Date: Qt' FOR DEPARTMENT USE O LY Application Accepted by Date 164 Area l u� E Pi or Grout nspection by Da r Final Inspection by Date F Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ 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 iIFEENFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. + 0£ 13-24IREV.iirs5) 35,vz� 35, EH 14-26 - [!