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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E' FtAZEL T ON AVE;1 STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED t (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Cdunry Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Y Job Address 18350 E. Mu n> o Avenue Cit Stockton, Cot Size 6+ Acres PM Owner's Name RMS DEVELOPMENT, INC. Address 7273 S. Nelson Road, Stockton Phone 209-462-9418 - r I u Contractor RMS DEVELOPMENT, �INCpddress Same License No. 555731 Phon,�fl9-462-9418 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout _ r—^ I I Irrigation _--Approx. Depth I-1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. . State Work Done Well Destruction El Well Diameter Sealing Material (top 501 i Depth f Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION 14 REPAIR/ADDITION l 1 DESTRUCTION l I INo septic system permitted if public sewer is q available within 200 feet.) Installation will serve: Residence X' Commercial T Other Number of living units: 1 Number of bedrooms 3 f Characer,of soil to a depth of 3 feet:`- Clay . Water table depth 100 Ft SEPTIC TANK,' ' -_ - L Type/Mfg) P&L Concrete Capacity 1600 Gal No. Compartments 2 PKG. TREATMENT P T ❑ Method of Disposal t 1.351 eat ..1Z Distance to nearest: Well . Foundation `- Property.Line LEACHING LINE IN No. & Length of'lines 2 Lines/85 Ft. Ea Total,length/size 1701/ FILTER BED 0 Distance to nearest: Well 1651 Foundation ,°x.35- ` - Property Line 85 SEEPAGE PITS IAF Depth ''�" 25 Ft. Size 36 Inch w Number 2 ^ k` F SUMPS L1 Distance to nearest: Well 200 foundation 60 ~Property Line_85,r . 3 DISPOSAL PONDS ❑ :i -1 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 Local Health District. 41 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 applicant ca f ,all requir inspections. Complete drawing on rovers S a. Signed Title: Date: FR DEPARTMENT USE ONLY Application Accepted by Date Area k Pit or Grout Inspection by Date Final Inspection by Date*N6 Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 .E.,Hazelton Ave.; P.D. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE ' AMOUNT REMITTED A5�1 RECEIVED BY DATE PERMIT'NO. INFO j r. 1qfD EH 13-2!iREV.t/k sl I J EH 14-28 �'^ y