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I o APPLICATION F8i4VAQVhOUNIY-PUBLICHEALTHSERVICBQ SAN JOAQUIN LOCAL HEALTW49NM4NTAL HEALTH DIVISION ` 1601 E. HAZELTON AVE., STOCSIM42IAL 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 well/pump and tho 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's Name Community Linen Service Address 1667 W. Washington Blvd. Phone(213}731-3132 os Angeles, CA 9U001 Contractor Pioneer Drilling Address 8300A Sierra College Blv 3icense No.250576 Phone (910797—OW 7 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER B 4 to 5 moniterin DISTANCE TO NEAREST: SEPTIC TANK �- 501 SEWER LINES 311 DISPOSAL FLD.�.200' PROP. LINE 10 W§ l s�, FOUNDATION 10 t AGRICULTURE WELL,-200 t OTHER WELD 2001 PITS/SUMPS P_2001 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2" t ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Schedule 4c PVC Specifications PI Public Cl Other CI Delta Depth of Grout Seal 311 Type of Groutcement + 57 } ts it I I Irrigation 45 _Approx, Depth I I Eastern Surface Seal Installed by PUMP be Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 211 Sealing Material (top 50'I 45 Depth } P Filler Material (Below 501 d TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic stem permitted if ^� F P Y P public sewer is available within 200 feet.l Installation will serve: Residence^ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK L1 Type/Mfg Ca acii P Y No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal `dT Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS I.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regutations of the San Joaquin Local Health DlJiriCt. Home owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, !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 on reverse side. Signed X Title:�, � Date: �/ 50 FOR R DEPARTMENT USE ONLY Application Accepted by Date 0 Area I'3� Pit or Grout Inspection by Date Q Final Inspection by Date 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 AMOUNT DUE AMOUNTREMITTEp INFO CASH RECEIVED BY DATE PERMIIT'NO. .-EH 13-24 IREV.1/A5) CL- / �! �.� O . 1 J EH 1428 Q