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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOA0,11.. COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 Now -REFUND LE PERMJT CALL 09 953-7697F0NSPECT/ONS EXPIRES 1 Y FROM TE ISSUED JOB ADDRESS _ Li�U(� /�� UCIT�Y//ZIP CROSS STREET W I ,1 / �_.LV _ APD9 5_L.� -'0 3O PARCEL SIZE -rrOWNER NA r w _ _. PHONE 1 1� OWNER ADDRESS l ""�- " - _ _CITY/STAT E/ZIP �-" ' `-''"'� �l CONTRACTOR D�A _- RdUk�A°I "�C PHON4616.-%6-7 CONTRACTOR ADDRESS __r .SV ° LICENSE ) C-42 ❑LIC -36 OTHER sAQ W' - 1 CITY/STATE/ZIP NUMBER [0015' I EXPIRATION DA' WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y _ ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK' NEW INSTALLATION ! REPAIR/ADDITION ENGINEER DESIGNED TER ❑ LEACH LINES REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER ft NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: ft FOUNDATION SEPTIC TANK TYPE/MFG C 1 _ CAPACITY gal # OF COMPARTMENTS,_ ❑ GREASE TRAP TYPE/MFG CAPACITY (gal # OF COMPARTMENTS If DISTANCE TO NEAREST: WELL It FOUNDATION _ _ ft PROPERTY LINE ft ❑ LIFT STATION SIZE --TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Receive Check#/ B Amount Rem' ed # OF LINES Permit/ Service Request # LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION - It PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH _ -_ ft LENGTH ft DEPTH _ ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE )QITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSAf M LAWS. 4 DATE 8764 Walnut I I I f A.j lication Accepted By_r�. L :�� _ _ .. /WIr" -I% NIAK _ • . ��rA-- k1F�°TM DCrr" PE Code SC INFO Receive Check#/ B Amount Rem' ed Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 11 0 v A M