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APPLICATION 3fgrq SAN JOAQUIN COUNTY PUBLIC HEATTHA -- Nn ( ed u{ ENVIRONMENTAL HEALTH DIVISI a 445 N SAN JOAQUIN, PHONE (209)4 } P O BOX 2009, STOCKTON, CA 9 201 FAC u PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDit O O (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 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. FRENCH Job Address 10995 S. NARLAN ROAD 4 CityORT ➢LVID— Lot Size/Acreage 51.9 AC Owner's Name STEVE DENET01 JR. Address "91Phone t-791`0 WONG ENGINEERS, INC. 4578 FEATHER RI A R.C.E. Contractor C. CHANCE WONG Address STOCSTON. CA 93219 License No. 14219 Phone 476-0011 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 Q ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public Cl Other fl Delta Depth of Grout Seal Type of Grout pQ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dora ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted it public waver is available within 200 feet.) Installation will some: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soli to a depth of 3 less rn m V� depth SEPTIC TANK ❑ Type/Mfg Capacity 1 D�sal PKG. TREATMENT PLT. ❑ Rh!�tAfl�� p Distance to nearest: Well Foundation--MV9ParlirM7fi TY AN LEACHING LINE ❑ No. & Length of lines �E� "fr A?,LIS�FpSUIVIQI WON - FILTER BED ❑ Distance to nearest. Well Foundation ��bty ewe SEEPAGE PITS 11 Depth Sire 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, and 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 persom subject to workman's compensa- tion laws of California." PERCOLATION TEST SA-94-31 The applicant must can fo MI required inspections. Complete drawing on reverse side. Signed x � � Tale: CIVIL ENGINEER Date: �6 0. ��' FOR DEPARTMENT USE ONLY Application Accepted by Date 2Ana Pit w Grout Inspection by Date Final Inspection by Data Additional Cormorants: "—`-' 'ti's"' 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 �} ZG2. INFO AMOUNT DUE AMOUNT REMITTED CASyH RECEIVED BY �(l PDATE 'yPEpERM/.I}TT NO. . C.ta-14 IaP•.,,.5r I $ 79. 43 EH 142!