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OWNER NAME�C L Jam^ + tnC-QE `G?<ck •k+Y.�....�C. <br /> ADDRESS <br /> t <br /> CITY/ZIP PHONE NUMBER <br /> CONTRACT43R <br /> �. CITY/ZIP PHONE NUMBER '7Y7 7,2 7F <br /> GEOGRAPHICAL INFORMATION: COORDINATES: X Y TOWNSHIP RANGE SECi'ION , <br /> TY E OF SEPTIC WORK: IN&15ALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> NEW INSTALLATION ]/RESIDENCE NUMBER OF BEDROOMS: <br /> ////D REPAIR/ADDITION D COMMERCIAL <br /> D DESTRUCTION D OTHER <br /> NUMBER OF EMPLOYEES: <br /> D ENGINEERED/ALTERNATIVE <br /> CHARACTER OF SOIL TO DEPTH OF 3': PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> ❑ PERCTEST(8) HOW MANY '�I APPLICATION# <br /> SEPTIC TANK TYPE/MFG 1!,f/1 l� T 'F CAPACITY C, <br /> #OF COMPARTMENTS <br /> O GREASETRAP TYPE/MFG CAPACITY #OF COMPARTMENTS <br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELLf <br /> ���, 4 FOUNDA710N15to i_ PROPERTY LINES 1 5--)_� <br /> ❑ LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) E <br /> #OF S: LENGTH OF LINES: C[� / G4 <br /> LEACH LINE bISTANCETONEARE.ST: WELL FOUNDATION PROPERTY UNE. V <br /> FLITRAT R CHAMBERS: �� I <br /> FILTER BED WIDTH LENGTH DEPTH DISTANCETONEARE.ST: WELL FOUNDATION PROPERTY LINE <br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> .� ❑ SUMPS WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH WNTANCETONEAll WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE PITS #_ DIAMETER -- DEPT J DISTANCETONEAREST: WELEr FOUNDATION/ PROPERTY UNE <br /> 1 HEREBY CERTIFY THAT I.Ib►VE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUfN COUNTY ORDINANCES,STATE LAWS <br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN M O A VAN •NO7`ICE REQUIRED FOR INSPECTIONS—PLEASE CALL(2091468-3423 <br /> SIGNED: TITLE: DATE: <br /> . <br /> I <br /> i <br /> I <br /> I _ <br /> ._� ._... _.:_.. _._.._..... .....:....... I <br /> ___-�_ _. <br /> ' I <br /> �. ._.L _.._.._ ..._.... _ .. �_._..... �........ l.__._.... - <br /> ._._ ......... <br /> i <br /> 111 <br /> - ....... <br /> -j -- <br /> po�..........__.,. <br /> _ <br /> .............. __+ I _ <br /> E <br /> I ; <br /> r(/. DEPARTME T'USE NLY (� C <br /> APPLICATION ACCEPTED BY: " k f-''� DAT1 O AREAMPLOVEE IDM�DISTRICT t LOCATION <br /> INSPECTED BY: DATE: PERMIT FINAL O YES DATE: INSPECTOR: <br /> COMMENTS: <br />