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it 'I 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 i� PERMIT EXPIRES 1 YEAR FROM�DATE ISSUED I (Complete in Triplicate) tom. 4 Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This I application is made in compliance with San Joaquin County Ordinance o. 51+9 and 1$62 and the Rules and Regulations of San +� Joaquin County Public Health Services. I� 11540 West Eight Mile Road CT[� �� Stockton ±5 acres Job Address )� City Lot Size/Acreage King Island Trailer Park & Rec. Co. P.O. Box 702, Stockton (209) 465-5883 Owner's Name Address Phone. V & W Drilling 10618 LambruSCO Drive 65786 "(7071 374-28 Address Contractor License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Heil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER &OilMonitoring Well ❑ ,, borings I P A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f D S OS L F LD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia:.of Well Casing n Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing .i Specifications C I"1 Public M Other 11 Delta Depth of Grout Sea! Type of Grout ! I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Done 13 Type of Pump H,Fl. ! State Work Done Well Destruction ❑ Well Diameter Sealing Material 4 Depth ` Depth. Filler Material & Depth 'I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Wo septic system permined if public sewer is G available within 100 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line ,f LEACHING LINE ❑ No. & Length of lines `Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation ) Property Line E �I s SEEPAGE PITS �.,l I Depth Sire Number -■ SUMPS Ll Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that 1 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 ,k 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 taws of California."Contractor's hiring or sub-contracting signature I certifies the following:"I certify that in the performance of the work for which this permit is iisued, i shall employ persona subject to workman's compensa- tion laws of California." a! The applicant m st call for all req fired in s: Complete drawing on reverse side. f Signed j 'L(f1, Title: _/�}e'I nit X I /Y)eL l A�ref_ Date: FOR DEPARTMENT USE ONLY Uhl'►+ Applicat Accepted by ' Date Area :f Pit or Grout Inspection by Data Final Inspection by Date 44 Additional Comments-. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009; Stkn, CA 95201 FFEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ��2 3 Page I3 h EH 74•2a