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Z ., d O <br /> ONSITE WAb...,�WATERTREATMENT SYSs� PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"FL-STOCKTON CA 95202 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS E• �TC CITY/ZIP l y <br /> CROSS STREET �/ APN ;* 6000"15 <br /> pPARCEEL(/SIZE � oy� 0lV . <br /> OWNERNAME :5 PHONE�V/' IZQj- 30/ <br /> OWNERADDRESS rIb(pu CITY/STATE/ZIP A. <br /> CONTRACTOR �l tc_ PHONE <br /> L <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> ���yyy NUMBER IF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> l� SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS Ct <br /> /❑ GREASE TRAP TrPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL fl FOUNDATION ft PROPERTY LME R <br /> ❑ LIFT STATION SIZE TYPE OP PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) r� <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION � ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SEEPAGE PITS NUMBER WfITTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANC QUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUINC TY. <br /> iNI1itUM //HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CAL 9)953-7697 <br /> SIGNE X offs TITLE PU4 P� DATE Q�O <br /> I V <br /> 01 <br /> 3 <br /> 75 YIN 1 11 <br /> AN JO Or Al <br /> p RT E <br /> DEPARTMENT/USE ONLY <br /> Application Accepted By Date S/3 Area Employee <br /> Final Inspection By Date 6TL/06 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Fb Pit/Sump Soil Character: <br /> COMMENTS <br /> 44--d L04 <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 - . <br />