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APPLICATION F6"01Q=COUNTY-PUBLIC HEALTH SEWCBS SAN JOAQUIN LOCAL HEALTfMgQhT?ffNTALHEALTH DIVISION 1601 E. HAZEL T ON AVE., STOcISPECIAL PERMIT Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weli/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 711 S. San Joaquin Street City Stockton Lot Size 1 Acre PM Owner Name Community Linen Service Address 1667 W. Washin ton Blvd. Phone(213)731-3132 os nge es, CA 90VU/ Contractor Pioneer Drilling Address 8300A Sierra College Blvd-cense No.250576 Phone (916)797-0447 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER k14 to 5 monitering DISTANCE TO NEAREST: SEPTIC TANK ❑501 SEWER LINES 311 DISPOSAL FLD.P 2001 PROP. LINE 10 we 15� FOUNDATION 101 AGRICULTURE WELLP�200 1 OTHER WELL>2001 PITS/SUMPS ❑2001 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `n ❑ Domestic/Private 19cGravel Pack ❑ Tracy Type of Casing schedule 4c PVC. Specifications f 1-1 Public (7 Other Ll Delta Depth of Grout Seal 311 Type of Groutcement + 57 I I Irrigation 451.Approx. Depth I I Eastern Surface Seal Installed by PUMP bents It Repair Work Done ❑ Type of Pump H,P. State Work Done 1� Well Destruction 1-1WellDiameter 2! Sealing Material (top 501 Depth 451 Filler Material (Below 501 c TYPE OF SEPTIC WORK; NEW INSTALLATION l 1 REPAIR/ADDITION I ] DESTRUCTION I 1 {No septic system permitted if public sewer is 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L-] 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, 1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applica t st call for all required inspections. Complete drawing onnJreverse 'side. Signed X • Title: Data: FOR DEPARTMENT USE ONLY r] l� Application Accepted by FC�.C�lYJ Date (�1 TO Araa Pit or Grout Inspection by Date Final Inspection by Date_Z13 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH13-24(REV.ti/H5) - b s� EH 14.26 �-0