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03/06/2002 11:03 2094683433 FIFTH FLOOR PAGE 02 <br /> APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCHTON, CA 95201 <br /> (209) 468-3447 <br /> ?RO <br /> PERrIT HTf�IRPSS� YEARYEAR FROM DATE ISSUED �j}�•" <br /> (Complete in Triplicate) <br /> Application 1s hereby mode to San Joaquin County for a permit to construct and/or install the work herein described. This ' <br /> application is made in compliance with.Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and.Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 75 West Valpico Road City Tracy, CA Lot Site/Acreage , <br /> Owner's Name Georgia-Pacific Corp. Address P.O. Box 105605 Pie (404)521-4650 <br /> jam 0 <br /> Contractor '^" sdt�'atella s �� License No. Phone --- ' <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT 0 DESTRUCTION 9 Out of Service hall 0 <br /> PUMP INSTALLATION C3SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK Unknown SEWER LINES Unknown DISPOSAL FLDUnknowrpROP. LINE 15' <br /> FOUNDATION50 AGRICULTURE WELL UnknowbTHER WELL 130' PITS/SUMPS 150' ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom ❑ Manteca Ola. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack Cl Tracy Type of Casing Specifications , <br /> (.7 Public (7 Other 0 Delta Depth of Grout Seal Type of Grout <br /> CJ luigalion _Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. Stas Work Done_ <br /> Well Davuction 0 Well Diameter 2 inch Sealing Material s Depth Cement grout w75% bentonite to TD , <br /> Depth 40.5 ft. Yiller Material i Depth Cement grout w/5% bentonite to TD <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION0 REPAIRIADDITION LT DESTRUCTION G (No septic system permitted if public sower 6 <br /> available within 20D feel.) <br /> Instillation will serve: Residence_ Commercial_ Other , <br /> Number of living units:_. Number of bedrooms <br /> Character of sok to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Typo/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLL 0 - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> G <br /> LEACHING LINE 0 No. If Length of lines Total length/sue S <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Lina <br /> Z <br /> SEEPAGE PITS I I Depth Sire Number _ <br /> SUMPS LI Distance to nearest. Well Foundation - Property Line ' <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify that I have pfopared this application and that the work will be done in accordance with San Joaquin county ordinances,stale laws,and <br /> rules and rapulaticns of the San Joaquin County <br /> Hone owner or Ilcenpd agent'''s signature certifies the following: "I comity that in the performance of the work for which this permit is issued,I shall not , <br /> employ any person in such manner as to become subject to workman's compensation laws of Cslifomis."Contractors hiring w wbcontracting signature <br /> certifies the following:"I cardfy that in the performance of the work for which shit permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of CallfwNa," <br /> The*policegt mustfor of re ired inspections. Complete drawing on averse side; ' <br /> Signed Title: Principal Hydrogeologist _ Date: 12/12/90 <br /> n R D ARTMENT USE ONLY . <br /> Application Accepted by �CJd✓/ Date Ada_--S to/� <br /> Pit or Grout Inspection by rDate Final inspection by Date 3 9/ <br /> Addhlonal Commend: Z ` <br /> Applicant - Return all copies to: gAN JOAQUIN OUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERWIT/SERVICES <br /> 443 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 53201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> 13.27 N 11.211*EV. <br /> It" irxal lt! ,� orr ), ` a� <br /> lY <br /> �1 <br /> 3 <br />