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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 1� (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 County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 18181 E. Munro Avenue City Stockton, Lot Size 7± Acres pM Owner's Name EMS DEVELOPMENT, ING. Address 7273 S. Nelson Road Stockton Phone 209-462-9418 � I Contractor RMS DEVELOPMENT,;jINCAddress SAME License No. 555731 Phone 209-462-941 TYPE OF WELL/PUMP: NEW WELL ❑ ' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 1-1MantecaDia. of Well Excavation Dia. f Well Casing EJ Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications k` I7 Public 11 Other Cl Delta Depth of Grout Seal Type of Grout----- I rout _I I Irrigation a Approx.IDepth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ � Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ` Depth Filler Material (Below 50'1 -- I TYPE OF SEPTIC WORK: VENSTALLATION REPAIR/ADDITION f I DESTRUCTION i I (Nosbetic syst m rented if public sewer is ^„ Installation will serve: Residence X Commercial_ Other ` Number of living units: 1 Number of bedrooms t 110 feet (� Clay — Loamy Clay Water table depth -)1— Character of soil to a-depth of 3 feet:' 2 SEPTIC TANK Type/Mfg. P' & L Concrete Capacity 2,000 gal No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal:Distance to nearest: Well 200 t Foundation 201aik_ Property Line 205 t 3/90' Total length 270' x 24" l LEACHING LINE No. & Length of lines r r g 110, FILTER BED ❑ Distance to nearest: Well 215 Foundation } 35 Property Line - G SEEPAGE PITS N Depth 25' Size 421r Number 3' . t SUMPS f_I Distance to nearest: Well 300 Foundation 130 Property. 100 DISPOSAL PONDS ❑ 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 Di1trict. i 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." k " The applicant m call for lI re. ' d inspect' ns. Complete drawing ori reverse side. Signed X Title: `�� Date: OR DEPARTMENT USE ONLY I 4 Date Area Application Accepted by Pit or Grout Inspection by Date Pinel Inspection by Date [ � F Additional Comments: i I ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, SA., CA 95201 i FEEAMOUNT DUE MOUNT REMITTED ASH07-1 RECEIVED BY DATE PERMIT'NO. INFO 1 _EH 13-24 IREV.t/n 51 1 r 4 EH 14-26 ,