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• APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 75 West Valpico Road CTracy <br /> Job Address ry Lot Size PM <br /> Georgia—Pacific Corp.- Address 75 West Valpico Road Phone (209) 836-2151 <br /> Owner's Name 4 <br /> Post Office Box 8045 937-9010 <br /> Contractor Brown and Caldwell Address W,lput' eke CA 94596 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL N WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> x ixiata Monitori®cDPen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> S cfications Cement/Sand <br /> ❑ Domestic/Private C3 Gravel Pack 0 Tracy Type of Casing P50 50 bentonite s carry <br /> C3 Public ❑ 110 Other ❑ Delta Depth of Grout Seal / / Type of Grout <br /> ❑ Irrigation 70/70/1-2--OApprox. Depth ❑ Eastern Surface Seal Installed by J• H. Kleinfelder <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nailabptic s temin ermined if public sewer is <br /> avle Installation will serve: Residence— Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well - Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side../ <br /> Signed , ', Title: rCo'�t 1>/— Date: /7 <br /> F ENT E ONLY g <br /> Application Accepted by <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: Drilling subcontractor: J. H. Kleinfelder & Assoc. , Stockton, CA (209)948-1345 <br /> ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635MM <br /> Applicant- Return all copies to;,Environmental ealth Pem7t/ rv1 s 1601 E. pzelton Ave P.O. Box 2DO9, Stk. CA 9520 Ie. <br /> orr mss, a/ � lw� ��,� <br /> FEEOUNT DUE AMOUNT REMITTED H flECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ♦ EH 13-24(REV.1/85) <br /> E 14-26 <br />