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00 APPLICATION .. :. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sae Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Count Ordinance and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Zk S M i Hillside Greens Golf Course T- Lilb y Trac Lot Size/Acreage T3S-R5E-S34 k Job Address j Par Green Partners 931-26th St. ,Bakersfield Phone (805) 322-•4673 Owner's Name Address (8 0 5) Bakersfield °°x'`1.600' E. lifornia License No. 440537 phone 324-6026 Contractor We 11 & *Pum Co Address Ca WELL y, WELL ® L REPLACEMENT R DESTRUCTION ❑ Out of Service Well L"1 TYPE OF WELL/PUMP: NEW OTHER ❑ Monitoring Well 0 PUMP INSTALLATION D SYSTEM REPAIR C7 SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK HER WELL, --P-ITS/.SUMPSr�----�.� i .l � •.,;, .�--� tip.=��FOLINDA710N= ��=:AGRICUL-TUBI= W.ELL-----•--_-----OI -- O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 12 d Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C92-012-269 : Type of Casing_ ROSCOe Mf?55 Specifications FI Domestic/Private N Gravel Pack C9 Tracy 5 6 0 r Type of Grout Ct nerlt Grow [� K Public 1-1 Other (� Delta Depth of Grout Seal 1 I I Irrigation 700Approx. Depth I I Eastern Surface Seal Installed by BakerSfleld Well & Pum fRepair Work Done 0 Type of Pump fV_FSub H.P. 5� _— State Work Done P 1 2° Sealing Material & Depth Well Destruction ❑ Well Diameter --Depth er Matial A Depth � �. Filler � TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I iNo sblei cyst m rented if public sewer is eet Installation will serve: Residence _ 'Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: t Capacity No. Compartments SEPTIC TANK ❑ "Type/Mfg PKG. TREATMENT PLT. ❑ - Method of Disposal I, Distance to nearest: Well Foundation Property Line I# f LEACHING LINE Ll No. & Length of lines Total lengthls ty Lina i FILTER BED El Distance to nearest. Well Foundation Property SEEPAGE PITS 11 Depth Size Number � SUMP_S L;1,gpistanca_to nearest:,,Well: _. Fqundation_ Property jnp_ — — DISPOSAL PONDS ❑ r 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 Home owner or licensed agent's signature certifies the following: "I certify that in the paiformance 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." Contractors hiring or subcontracting signature canifies the following: "I certify that in she 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 m call for all required ' spections. Complete drawing on reverse side. Sales 6-9-93 Signed X 0• Title: Date: FDE RTMENT USE ONLY - �-1-16f_ae.7Application Accepted by Date Area I Pk or Grout Inspection by Date .Final Inspection by Date _ t" Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services -7- + Environmental Healtb Permit/Services1 445 N San Joaquin, p O Box 2009, Stkn, CA 9520 FEE AMOUNT Dt1E AMOUNT REMITTED �K A RECEIVED BY DATE PERMIT NO. „ CASH lioEM,3-24 t ,..m,IREV.s,R s) v`C7 �(7 C)