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` PUBLIC HEALTH SERVICES SAN JOAQUIN COUNTY P. O. Bax 2009 (1601 East Hazelton Avenue) - Stockton, venue)Stockton, California 95201 s } JIM t 9g. PERMIT EX n 1 ES 7 YEAR FROM DATE ISSUED � c� � L (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work beret ``fly r made in compliance with San Joaquin County Ordinance No.549 for sewage Sr No. 1862 for well/pump and the Rules and Aelf�applrcation is Local Health District. g4,fg�J sof the San Joaquin ©9-7 X3 gab address Lincoln Village Center Stockton City '' Lot Size PM Owner's Name Lincoln Properties , Ltd Address 374 Uncol n Center 2. Stockton Phone 209/478-9200 Contfaclor ' PC Explorationphone Address 1780 Vernon St. , Ste,E No,License . 265556% 916/783-973 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ i SYSTEM REPAIR ❑ , . OTHER [X Monitoring Wells DISTANCE TO NEAREST: SEPTfC TANK SEWER LINES DISPOSAL FLD. PROP. LINE & 50 l l boil g FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial, ❑ Open Batlom ❑ Manteca Dia, of Well Excavation-W-OX-22—in Dia. of Well Casing r 0 DomestrclPrivate ❑ Gravel Pack ❑ Tracy Type of Casin FVC Steel -- 1: Specifications XI Public X n Other n Delta Depth of Grout Seal VaT`10 S p - P%nfype of Grout Ce ent 1 I Irrigation Approx. Depth 11 Eastern Surface Seal Installed by r Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ' ;, ❑=:. Well Diameter Sealing Material /top 501 s Depth Filler Material (Below S01 TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAiA/ADDITION f I DESTRUCTION I I iNo septic system permittejdpubfic,sewer is s available within 21x1 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 ' ;r. SEPTIC TANK. = ❑ Type/.Mfg Capacity -_ No. Compartments PKG. TREATMENT PLT C7 Method of Disposal Distance to nearest: Well . Foundation Property Line _ 1, LEACHING LINE ❑ .No. & Length of lines Total length/size FILTER SED . C] Distance to nearest: Well Foundation Property Line N A' e SEEPAGE.PITS "` 11 Depth Size Number sumps ,' N. A Ll :Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS t'] e hereby certify 11W.1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, i rules and requlauuns of the San Joaquin Cdcal Health District. Home owner of licensed agent's signature certifies the followhW: "I certify that in the performance of the work for which this permit is issued. I shall. qVi employ any person in such manner as to be ome subject towork an's compensation laws of California."Contractor's hiring or subcontracting signal certifies the followin d tf r a of t a rk for ws permit is issued, I shall amhich this lion laws of Calif •t1 ri< i' T Pto Y Persons subject to workman's.compan The applica i 'tttrar � I1 - m ate drawing on reverse si¢(,� t� Signed XTitlo-- L/// 7/25/90 Date: Title Q FOR USE ONLY -4, Application Accepted by Date Ara s Pit ar Grout Inspocton byDate Final'jhspecuon b Date/// Additional Comments ❑,Stk,:466.6781 ' ❑ Lodi 359-3621 ❑ Manteca 8237104 ❑ Tracy 1335-5385 Applicant - Return all copies,te. Environmental Health.Permit/Servicas 1661,E. Hazelton Ave., P.O. Box 2009, Stk., CA 952Q1 FEE AMOUNT DUE AMOUNT AEMITTED CK s - RECEIVED dY irrrFO CAS>r DATE PERMIT ND. -` tstuy - r