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.d APPLICATION FOR PERMIT m _ (.: 15 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 ! P=IT EXPIRES 1 YEAR rROM _DATE ISSUED i (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. j Job Address 4851 East Woodbridge Cit Acampo Lot Size/Acreage 2 acres owner's Name Robert Bieffel Address same Phone 369-1819 f Contractor Clark Well Inc Address 2024 E. Charter Wa License N632 560 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT k1 DESTRUCTIONyaOut of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 7 5 r SEWER LINES, DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom 0 Manteca Dia, of Well Excavation 1211 Dia. of Well Casing( 51AII Xf1 Domestic/Private Gravel Pack C1 Tracy Type of Casing ,Z-ePl Specifications 10 .,,,-cj- M Public l l Other ❑ Delta Depth of Grout Seal 3 5 0 r Type of Grout 2 $ra C:lc `° * CJ Irrigation Approx. Depth Irl Eastern Surface Seal Installed by Clark Repair Work Done L7 Type of Pump H,P. 2 State Wgrk Done Mows fi.Gi-ygel..j. _ Well Destruction O Well Diameter6 rr Sealing Material k Depth �s }�,ttg;#e Lop both- we ls 2"we i s Depth 3$0 r Filler Material L Depth TYPE Of SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADOITION Ll DESTRUCTION G (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; ❑ Typo/Mfg Capacity No. Compartments" PKG. TREATMENT PLT. 0 Method of Disposal. Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ` LI Distance to nearest: Well Foundation Property Line biSPOSAL PONDS ❑ ` I hereby certify that I have preored this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County 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 subcontracting signature I certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to wo'rkman's compens E tion laws of California." The applicant' s )call r r9�i ".cfi s. Complete drawing on reverse side'. VP Clark Wel 18 Oct 90 Signed ?L - _ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by CAL.. YV- Date Std--�� Area C��t Inspection by ate ��dFinal Inspection by �` Date' �_z / Additional Comments: x t'�1 6 -Io ?b Applicant - Return all copies to: SAN JOAgUIN C TJNTY PUBLIC HEALTH SSRVIC&S ENVIRONMENTAL bA7a's ?,a- 445t7' N SAN TAL HEALTH DIVISI2008PERMIT/SERVICES TOCKTONCA 95201 f �f FEE INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERM17'NO. ' , r j r IY 14.26 V.I? 5P0— 1,9 -2--7 re f