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APPLICATION FOR PERI![I T I; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCSTON, CA 95201 (209) 468-3447 I pPM13: ESPIRES 1 YEAR-PRQ9 DATE 3S�UED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of ban Joaquin Colony Public Health Services. 21760 N. TretReway Acampo Lot Size/Acreage 3 1 /2 acres , Job Address Cty Owner's Name Marvin Sprenger Address same Phone 369-87$5 Contractor Clark Well , Inc Address 2024 E. Charter Ka!X License No371560 Phone 452-7676 TYPE OF WELL/PUMP: NEW WELL)�K WELL REPLACEMENT C-1 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, -PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED_ USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial C3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 518' Yt JT)omeaticlPrivate 1 ravel Pack 0 Tracy Type of Casing Steel Specifications 1 M Public 1:1 Other ❑ Delta Depth of Grout Seal 10 0 Type of Grout 9 sack U Irrigation ,_._...Approx, Depth 0 Eastern Surface Soul Installed by C lark Repair Work Done L7 Type of Pump Sub H.P. 2 State Work Done install Well Destruction O Weil Diameter Shing Material & Depth Depth { Filler Material & Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI INo 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 I SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size Y FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 ` rules and regulations of the Sen Joaquin County 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 employ any person In such Manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature certifies the following: "I comily 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 sppGcan all r t r ired •n c n Co plate drawing on reverse side. Signed Zz Title:VP Clark Well Inc - Date: 3/19/91 ARTMENT USE: ONLY q 1 I Application Accepted by Date 3-I'{- 1 l- Area — Pit o Grout I spection by Date 3� Final Inspection by Data -2� Additional Comments: �{ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I� 445 H SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 98261 r ;NFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. . EH 13•241AEv.i/x61 �� 3—/9-13( r 0lil- EF4 if•20