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APPLICATION FOR PERMIT . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 Rr PE_UIT EXPIRES 1 YEAR VRQM DATE ISSUED �� (Complete in Triplicate) Application is hereby made,to San Joaquin County 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 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 75 West Valpico Road City Tracy, CA Lot Size/Acreage Owner's Name Georgia—Pacific Corp. Address P.O. Box 105605 Phone (404) 521-4650 y L 5 l0 J iLicense Ice, s e N C" �----) Convector �''�'�t ° - . License No'' /� J � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EVENT ❑ DESTRUCTION 1G Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well X7 DISTANCE TO NEAREST: SEPTIC TANK Unknown SEWER LINES Unknown DISPOSAL FLDUnknowrpROP. LINE 15' FOUNDATION 50' AGRICULTURE WELL Unknow'15THER WELL 130' PITS/SUMPS 150' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 13 Public 1-1 Other ❑ Della Depth of Grout Seal Type of Grout G Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction f3 Well Diameter 2 inch Sealing Material i Depth cement grout w77% bentonite to TO Depth 40.5 ft. Filler Material i Depth Cement grout w/5% bentonite to TD TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION L1 DESTRUCTION CI (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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line c LEACHING LINE U No. 8 Length of lines Total length/size C FILTER BED CI Distance to nearest: Well Foundation Property Line Z SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 County S 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." Convector'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 applics t must 1 for all re ilrad inspections. Complete drawing on reverse side. Signed 7 J Title: Principal Hydrogeologist Date: 12/12/90 FpR DFfARTMENT USE ONLY ) / Application Accepted by 7'l(// Dace f 1 Area---2R1�5 Pit or Grout Inspection by I ell r Date Final Inspection by, Data Additional Comments: 2-- ✓ ` ' �� Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. INFO n . EH 13311aEV.11x51 (06 5- 3y' EH use 11l