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5 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 L/ t City Stockton /g-/N4 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 -(707:l 374-28 Contractor ddress Phone License No. TYPE OF WELL/PUMP: NEW WELL 1=1 WELL REPLACEMENT fl DESTRUCTION CI Out of Service Well 0 E-3 ng PUMP INSTALLATION 0 El SYSTEM REPAIR OTHER MS0 i 1Monitot:i Well borings 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 El Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private Cl Gravel Pack Li Tracy Type of Casing Specifications I'l Public Cl Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation . Approx. Depth 1 I Eastern Surface Seul Installed by Repair Work Done U Type of Pump H.P. State Work Done g Well Destruction 0 Well Diameter Sealin Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION 1 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 soil to a depth of 3 feet- Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE El No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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, an 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 applica must call for all req ired inspec 'Ons. Complete drawing on reverse side. i App 'cello Accepted by . 61/ FOR DEPARTMENT USE ONLY Date 4FG Area y) Pit or Grout Inspection by Date Final Inspection by Date Additional Comments• Job Address ±5 acres Signed Title: Date: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE ' , - Ono (.__ 96 5",200 6?2,-2_2- c°\ EH 13-24 (REV i s) EH 14-2e 2_,L:?_-