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APPLICATION r SAN JOAQUIN COUNTY PUBLIC HEAL H 16 4Q�E7 60 ENVIRONMENTAL HEALTH DIV SIO �D r JOST 445 N SAN JOAQUIN, PHONE (20 )a �' 20 P 0 BOX 2009, STOCKTON, C 9 �0 �. ;i PERMIT EXPIRES 1 YEAR FROM D A (Complete in Triplica epfl # Application is hereby made to San Joaquin County for a permit to construct an e i application in made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations gofr ban Joaquin County Public Health Services. Job Address 4767 East Harvest Rd City Acampo Lot Size/Acreage Owner's Name JR Metzger Address same Phone 332-8047 1 Clark Well , Inc . Address2024 E . Charter Contractor License NO 71560 phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTxBA DESTRUCTION XXOut of Service Well ❑ PUMP INSTALLATION)CI SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ €' 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 5/8- X 8tX 7A Domestic/Private x flxGravel Pack ❑ Tracy Type of Casing_ Steel- Specifications t n (� I'1 Public r�to glher P Delta Depth of Grout Seal Type of Grout 4 ca r k 11 Irrigation Xk�Approx. Depth l l Eastern Surface Seal Installed by_ Clark - -- Repair Work Done 0 Type of Pump Sub H.P. 1 1/2r— State Work Done tri S t a 7 7 _ Well Destruction x)Ek x Well Diameter 6 n Sealing Material & Depth 9 s a c k Depth .0 n k n O WrL_ 140' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted it public sower is Ri available within 200 leet.l 'Installation will serve: Residence Commercial— Other Q €;Number of Living units: Number of bedrooms "1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ` q Distance to nearest: Well Foundation Property Line (JOU LEACHING LINE ❑ No. & Length of lines Total length/size FILTER-DED C7 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 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 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 applicant s1 all f r a I i s. mplete drawing on reverse side. Signed Title: _ VP Clark__MP-1-1 Date:6 t`l,-r 3 FOR DEPARTMENT USE ONLY Application Accepted by Date vIt, Area Z Pit orGrout nspection by Date rD `y f3 Final Inspection by 1 Date Additional Comments: t �� G pc L r r 4A L� Appl cant - Return all copies to: San Joaquin County Public Health Sery es�l211& Environmental Health Permit/services �,� sr u��] 445 N San Joaquin, P 0 Box 2009, Stkn, CA 952010 N ' �, t ( t INFE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE nPERMI 'NO.�EM 13.2411rtV.i/Msr �; � , �1 � 73 �(�) `/� j .-EH 14.20 r I v UL H151,_ ci ' 4o Y 3- ZO X 415