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1 SITES 3&4 t MIDDLE RIVER CROSSING r A° APPLICATION FOR PERMIT , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION IP O BOX 2009, STOCXTeN-, -CA 95201 (209) 468-3447 %t14�1JOda X R PROM DATE IsgIJ�4®Q (Complete in Triplicate) Application is hereby made County for a permit to construct and/or install the work herein described. This application is trade in compliance -with San Joaquin County Ordinance No. 549 and 1862 and the Rules amd Regulations of San Joaquin County Public Health Servi;ces. 3)APIA Job Address South Side Hwy. 4 @ Middle River 4 )AF N City Lot Size/Acreage N/A r 3) Whiting Welch Trusts 3) 332 Market St. ,Ste. 2700, SF, CA 3) (415)957-130 Owner's Name 4) G. Nichols Address 4)13762 First Ave, Hanford CAP hone 4) (209)465-560 P.O. Box 50367 Contractor Pitcher Drillin .CoAddress Palo Alto CA 94303 License No. 263085 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (`1 Phone 415 328-391 I DESTRUCTION ❑ Out of Service Well ED PUMP INSTALLATION ❑ SYSTEM REPAIR L] OTHER ❑ Monitoring W 1 DISTANCE TO NEAREST: SEPTIC TANK �!— 1-50' 7 50' n3 SfWER LINES DISPOSAL FLD._rso, PROP, LINE. >50. FOUNDATION; 50 AGRICULTURE WELL 750�OTHER WELL 50� ��... PITS/SUMPS �50' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industriat ❑ Open Bottom C] Manteca Die. of Well Ertcavarion2 U Domestic/Private ❑ Gravel Pack Dia. of Well Casing n Tracy Type o/ Casing PVC Specifications Schedule 40 Q Public Xl Other $] Delta Depth of Grout Seal CJ Irrigation 90' A Depth Type of Grout Bentonite & pprox, Depth ❑ Eastern Surface Seal Installed by Tremmie Grout Cemeht Repair Work Done U Type of Pump 1 H p State Work Done w Well Destruction ❑ Well Diameter ' Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/ADDITION Cl DESTRUCTION C! INo septic system permitted if public sewer is Installation will serve: available within 200 feet.) Residence_ Commercial Other C Number of living units: Number of bedrooms tj Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation _ property Line LEACHING LINE Cl No, 8 Length of lines FILTER BED Total length/size n Distance to nearest: Well Foundation Property Line F: SEEPAGE PITS I I Depth Size SUMPS Number LI Distance to nearest: Well Foundation p15P05AL PONOS ❑ ----- Property Lina 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 signsture 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, t shall employ persons subject to workman's compensa- tion laws of C i ornwe The applics 1 c require insPections. Complete drawing on reverse side. �/ q Signed 4 Title: 1-4 "04&XDate: ! ` 1 FO DEPARTMENT USE ONLY Application Accepted by _ -r Date P�`l Area Pit or Grout Inspection by Date t Final inspection by Date�T Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 EAMOUNT DtJE AMOUNT REMITTED CK GASH RECEIVED BY DATE EN A-M - .