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' OWNER NAME l.,oK S�fztSS t r r�,T\ZT_ CPHONE q LA 9— oT9 L y <br /> OWNER ADDRE`SS�, CITYISTATE21P <br /> CONTRACTOR�r}yfcrS7 � ✓�� 2I�IZa�CF-� 3rC• PHONE � <br /> ' CONTRACTOR ADDRESS &'.PaaF F+ew�vVE'7T CITY/STATE/ZIP trdcS�'fl 4535 5 <br /> LICENSE ❑C-42 ❑C-36 OTHER C'7+` NUMBER XI I%t�(0 EXPIRATION DATE g 2.-S, 2 00c� <br /> ' WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I I BUILDING PERMIT# LAND USE APPLICATION# <br /> ' TYPE OF WORK: G NEW INSTALLATION 7 REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMM9EAF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ' SEPTIC TAN TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> (3 LEACH LINES E LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> ' DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O FILTERBED WIDTH ft LENGTH ft DEPTH ft p� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O MOUNDED WIDTH ft LENGTH ft DEPTH It N <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> n <br /> 0 SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> ' DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> O DISPOSALPONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 SEEPAGEPITS NUMBER WIDTH ft DEPTH ft ,\ <br /> ' DISTANCE TO NEAREST WELL ft FOUNDATION ft. PROPERTY LINE ft (� <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, n <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. h <br /> ' MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED -�� �J�— �' J TITLE DATE <br /> � I <br /> ' J <br /> R O U <br /> ' DEPARTMENTU OLY <br /> Application Accepted B Date e Area Employee 0# <br /> Final Inspection ' Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to,De of 3-Ft; Pit/Sump Soil Character: <br /> COMMENTS «1( X�Ali 4� /iX� Jr . <br />