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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA rr AY M E N 1 Telephone {209) 466-6781 RECEIVED PERMIT EXPIRES TYEAR FROM DATE ISSUED 1E,j rC:1 � (Complete in Triplicate) JUL a � 1990 �--� 0rs-0 20-3 7 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 an&@xWRQNMEFN-fA4t44EAiL"1San Joaquin Local Health District" "'�PM1TISFRVI(_.FC Job Address Woodbridge Waste Water Treatment Plant City Woodbridge Lot Size 12.5 acres PM Owner's NameWOOdbridcJe Sanatory Dist.Address P.O. BOX 299 W.S.95258Phone (209) 368-0900 95691 Contractor WeStex Address P.O. BOX 1664 West Sac License No.552198 Phone — 8 TYPE OF WELL/PUMP: NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION © - PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION— — AGRICULTURE'WELL" +OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation 0 Dia. of Well C in ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing PVC Specifications S1larry W f'] Public ) Other (M torj elta Depth of Grout Seal Type of Grout I i Irrigation 5-W.-Approx. Depth I I Eastern Surface Seal Installed by WE—SteX Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 4° Sealing Mateiial (top 501 e Depth 50' Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 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 r. PKG. TREATMENT PLT. ❑ Method of Disposal [� Distance to nearest: Well Foundation Property Line wl LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line w � � DISPOSAL PONDS ❑~ y ~� 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 must call for all requir d inspections. Complete drawing on reverse side. Signed X Title: S � �� 'ca`S"C Date: FDR DEPARTMENT USE ONLY r Application Accepted by Data T' Q Area r Pit or�;�)spection by+U�!lr�\\ Data+—I S Yly Final Inspection byI�--�� Date Additional Comments: 1 d 4-,�A :V�� e,,-.l C] Stk 466-6781 ❑ Lodi 369 ❑ Mante 823-7104 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CA H + EH 13-24(REV.t/K51 ` O EH 14-2e �� d0 �7C^ / 199-1-7