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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE ( 209 ) 468- 3420 P 0 BOX 2009 , STOCKTON , CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( 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 . 11530 West Eight Mile Road &N� /5 L1 city Stockton Lot Size/Acreage ±5 acres Job Address " King Island Trailer Park & RPr - Co . P . O . Box 702 , Stockton ( 209 ) 465 - 5883 Owner's Name Address Phone V & W Drilling 10618 Lambrusco Drive 65786 ( 707 ' 374 - 28 5 Contractor Address License No. Phone TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER dSOi 1Monitoring Well ❑ borings` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ SUMPS (\ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.. of Well Casing C.1 Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I '1 Public I:1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Soul Installed by (� Repair Work Done U TypeofPump H . P. State Work Done _ C Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK : NEW INSTALLATION I I . REPAIR / ADDITION I I DESTRUCTION I I (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 wil to a depth of 3 feet: Water table depth SEPTIC TANK . ❑ Type/ Mfg Capacity. No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/ size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ani AI 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, 1 shell not employ any person in such manner as to become subject to workmen'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 applica ► mu call for all req ired inspe ti ns. Complete drawing on reverse side. Signed Title: �e ii��7 � �'/a" i` f� Date: f� ///�/ � FOR DEPARTMENT USE ONLY App Icatio Accepted by // / Date - 96 Areb 4F a Pit or Grout Inspection by - Date Final Inspection by Date Additional Comments: C II/ Applicant - Return all copies to : San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin , P O Box 2009 , Stich , CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / OATE9/ PERMIFEET' NO. FORPage I3A R Il.24 IREV. irx5) a 9 2�/ • ( � 3 / Io D0822v H r.A