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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON* CA 95201 <br /> (209) 468-3447 <br /> PERMIT URIRES I MAR OROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coupliance-vith San 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 Size/Acreage <br /> Owner's Name Georgia-Pacific Corp. Address P.O. Box 105605 phone (404)521-4650 <br /> Contractor s License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION If Out of Service Well ❑ <br /> PUMP INSTALLATION-0 _SYSTEM REP.AIR_C7s,_ , _ _..OTHER CI_ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK Unknown SEWER LINES Unknown DISPOSAL FLDUnknowrpROP. LINE 15' <br /> FOUNDATION 50 AGRICULTURE WELL linknawbTHER WELL 130' PITS/SUMPS 150' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> M Public Cl Other 0 Delta Depth of Grout Sea[ Type of Grout <br /> 0 Irrigation Approx. Depth 0 Eastern Surface Setrl Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction 13 Wali Diameter' 2 inch Sealing Material i Depth cement grout w77% entonite to TD <br /> Depth .40.5 ft. Finer Material & Depth _cement grout w/5% bentonite to TD <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence-f Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth v 1 <br /> SEPTIC TANK. C1 Type/Mfg t Capacity No. Companments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> • <br /> Distance to nearest: Well Foundation Property Line <br /> f <br /> C <br /> LEACHING LINE ® No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line �--� <br /> SEEPAGE PITS I I Depth Size Number ` <br /> SUMPS LI Distance to nearest: Well Foundation Property Line O <br /> DISPOSAL PONDS U <br /> 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 <br /> rules and regulations of the San JoaquiniCounty <br /> i. 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 subcontracting 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 /> Thea fits t must I for all re fired ins ion I in <br /> PP pest s Complete drawing on reverse side: <br /> Signed K Title: Principal Hydrogeolo ist Date: 12/12/90 <br /> k <br /> F R f3 ARTMENT USE ONLY <br /> Application Accepted by Date Araa�_ <br /> Pit or Grout Inspection by Date Final Inspection by Date 3 9l <br /> Additional Comments: l <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> .445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> . FHU•24IREV,1/ Sl <br /> [HA-a8 lS! a 3(`y/ <br /> ISSI! <br />