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VI0I } � �� V PI � � �NV1 ,,! 66.3420 I � � II L I JJJ I i I , € `"'°� ,I NON- EgONUAFit.F.PERM r- - APN BUILDING PERMIT JOB ADDRESS ` CITYfZ1P NUMBER i pWNER NAME i� �PHONE Cil'YlZIP .ADDRESS 57- .......... CONTRACTOR PHONE NUMBER S �� SECTlON�1 RANGES CtTY1ZIP TOWNSHIPS Y GEOGRAPHICAL INFORMATION: COORDINATES', x NUMBER OF LIVING UNITS INSTALLATION WILL SERVE: NUMBER OF BEDROOMS: TYPE OF SEPTIC WORK: € a RESIDENCE ❑ NEW INSTALLATION II !'. ❑ COMMERCIAL NUMBER OP EMPLOYEES: Cl REPAIRIADDlT10N ❑ OTHERr C ❑ DESTRUCTION L ❑ ENGINEERSDlALTERNATIVE WATER TABLE DEPTH: PIT/SUMP SOIL CHARACTER: CHARACTER OF SOIL TO DEPTH OF 3% APPLICATION# JK PERC TEST(S) HOW MANY CAFACiTY Of COMPARTMENTS iiii��` - M Cl SEPTIC TANK TYPE/MFG #OF COMPARTMENTS CAPACITY ' _❑ GREASE TRAP TYPEIMFG - - - - - © PROPERTY LINE PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION - — - ❑ rYreoF ruMr SAND OIL SEPARATOR(E[3CLOSED SYSTEM) LIFT STATION SIZE - ❑ #OF LINES: LENGTH OF LINES: DIsrANCETONtAaexT: WEI:L FOUNDATION PROPERTY LINE- LEACH 'LEACH LINE INFLITRATOR CHAMBERS: '❑ FILTER BED WIDTH LENGTH DEPTH' - DISTANCE To NEAREST: WELL FOUNDATION PROPERTY LINE ❑ MOUNDED WIDTH- LENGTH DEPTH DISTANCE TONEARV-%T: WELL FOUNDATION PROKRTY LIKE A SUMPS WIDTH! -LENGTH DEPTH DISTANCE TO NEAREST: WELL - - - FOUNDATION PROPERTY LINE ❑ DISPOSAL PONDS WIDTH LENGTH - .DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ❑ SEEPAGE PITS # DIAMETER - DEPTy DISTANCE TO NEAREST. WELL FOUNDATION PROPERTY LINE-- I HEREBY CERTIFY INEIHEREBYCERTIFY THAT 1 HAVE PREPARED T APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN COUNTY ORDINANCES,STATE LAWS ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. �I A CE NOTICE REQUIRED FOR INSPECTIONS,-PLEASE CALL 009)468-3423 SIGNED: • !� TITLE: ��+`+ I'etJl�� _I 1 t �._.,._.-1 j I _p.,.._.,. .,.f ._ I ... I - I .,i-S.w._.I I € F ... �.. I € EF Y {I f .__ -- - - ._� _' 1. I ti FED RAS MAHIU BRIGGS R V R.-y¢I r} CDEL D. RD, t9 ! a FREwERr NLD 4 _'. f... AV. S�IUIRF.S q cc 1 _ i iq� DE LIMA RD.a ARD 3.3 - .- p m a f GY,a05 REIS CD.vx. r a � + OOS REIS RD- .:, '- � LATH-4 Lathlop 1 i TNDMSEN F 1 O AV- LOUISE .7 L.2A a V. - TrSq{, _ --- ---- A 5fT PL,4N , f _ _ 4 a � L F I I I I W i f L.. � r ; AC�:fO-ia IIvats�TYr APPLICATION�-qCC TEp � }lm - - I .. - r /ti DEPARTMENT USF,'ONLY I. gv: V L.•"KA V � -- �z ENVIRONMENT fiEALTH DIVISION �.: �*`•� ��-��,..,- EMPLOYEE 1D#. DISTRICT INSPECTED BY: � ,..� � LOCATION DATE' �/ O Q PERMIT FINALy-yES DATE: � - COMMENTS: •�•r /i/ A T, INSPECTOR: f ;�• .i/ s. F PE CODE SC INFO AMOUNT .HEC ASH RECEIVED REMITTED DATE I , gy PERMIT/SERVICE REQUE57p - _ INVOICEq SEPTIC,ID.9 II - I ',