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4 APPLICATION FOR PERMIT +�+ SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE:TON AVE\, STOCKTON, CA Telephone Q09} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 F made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. lStockton Lot Size 5+ Acres PM Job Address 18475 .E: Munro Avenue city r209-462-9418 Owner's Name RMS DEVELOPMENT, INC. Address 7273 S. Nelson Road Stockton Phone Contractor RMS DEVELOPMENT, INC Address Same License No. 555731 Phane209-462-9418 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 'SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F.LD. PROP. LINE FOUNDATION AGRICULTURE WELL . OTHER WELLPITSISUMPS 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 I-1 Public i-I Other ❑ Delta Depth of Grout Seal Type of Grout — 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 ❑ Well Diameter: Sealing Material (top 501 — Cx- Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NE STALLATION REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is { available within 200 feet.) `tn] Installation will serve: Residence X Commercial_ Other r Number of living units: 1 Number of bedrooms 3 Character of soil to a depth of 3 feet Clay Water table depth (� i� SEPTIC TANK Type/Mfg P&L Concrete Capacity 160OOa1 No. Compartments ` PKG. TREATMENT PLT. ❑ Method of 7Disnposal r 17C 1: t2V_t. Distance to nearest: Well_ ';" Foundation 20" - 1Property Line �r t i " Lines/85--XIt 5 LEACHING LINE N No. & Length of lines 2 Total length/size FILTER BED El Distance!o nearest: Well 165' Foundation 35 Property Line $5 F SEEPAGE PITS KI Depth 25 Ft. Size__316—Inch _ Number I,f 'SUMPS 0 Distance to nearest: Well 20()_."— Foundation { 60 _ Property Line R 5 t n i DISPOSAL PONDS ❑ t ! 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. 1.- � 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 o(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,t shall employ persons subject to workman's compensa- tion laws of California." l The applicant t call or all re uired in ctions. Complete drawing on reverse side. ,. +� d Title: Signed X f.5 C I Date: ^�' FODEPARTMENT USE ONLY I Application Accepted by Date Area Dater Final Inspection by Date .�C Pit or Grout Inspection by ' r } Additional Comments: F ElStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services:1601 E. Hazelton_Ave., P:O: Box 2005, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. INFO r '! Q -�///� 19DEH 13"24{REV.r i n 5) 1 U ! " - fill {l EH 11-28 / (,