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NtJUINIOVNiY ENYI1lVwMC.AlA411LALllf OLYAwIMGw I —a rr cuaw rare— rl. —a"va k—l-- <br /> -REFUNDABLEIP�ERMITG CALL 209 953-7¢0"FORIINSPECTIONS A_EXPIRES/IIY�1E'A1R�FROMDATEISSF-'� <br /> e ADDRESS r� {V D�Yy. - r� ACFFY/ZIP F�Ky,QYY1(,1d1 { p p � <br /> CROSS STREET 1 l.�11 KL.t- PN 4' V,�^ -1 PARCEL SIZE I'1�.A lxt p <br /> OwNERNAME }{C({(,1(G'� NworI flip IA C D PHONEIby`-'1 2ST' ke <br /> OWNER ADDRESS l N(1 ;r k�- CITYISTATEJZIP 1 1{drY►an�,1^- CAf�Q1iU% <br /> CONTRACTOR NM PHONE ✓`'�_ V� <br /> CONTRACTOR ADDRESS CTry/STATEIZIP <br /> LICENSE ❑C-02 ❑C-36 OTHER NOMnER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> JEr FERC TEST # BUILDING PERMIT# LAND USE APPLICATION# O <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG-TX PLANT DtsrANCETO NEAREST: WELL A FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OP PUMP ❑ SAND OIL SEPARATOR(ENcLosco SYsrEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R r� <br /> DISTANCLTONEARFsT WELL It FOHNDATION fl PROPERTY LINE ft <br /> ❑ FILTER SED WIDTH ft LENGTH ft DEPTH ft ' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LME ft <br /> ❑ MOUNDED wwTR R LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE R ,1 <br /> ❑ SUMPS Wuyru ft LENGTH ft DEPTH R <br /> DIsTANCETONEARFST WELL R FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH. ft LENGTH B DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft (� <br /> 1 HEREBY CERTIFY THAT T HAVE PREPARED THIS APPLICATION AND THE WORK WILL DE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. +T' Tl <br /> MINIMUM 1 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLE CALL(209)953-7697 ) <br /> SIGNED - _ -- _ DATE �7 LP•O,� <br /> s <br /> J/WAx R0.4U ti <br /> I <br /> 7?, JDA <br /> � a err <br /> I PARCEi T PARCEL 3 <br /> ua�mur A <br /> {�with a.mss rw:msrM <br /> I �iV 4 bora tnrl � i I., <br /> T C U <br /> cwonen �� i �L-O 2 <br /> I i <br /> i <br /> i <br /> I DEPARTMENT USE ONLY T <br /> Application Accepted By --— Dai. �-�-!LC dS Area Employes ID# `�34 ro I q 5 <br /> Final Inspection B} D: ❑ SPECIAL PERMIT-Approved by <br /> Character of Sail to Depth of 3 • - IHSump Sail Character: <br /> COMMENTS / �L7 / f� <br /> -6,1G CZ' <br /> PE SC Received a Amount Date Per tf <br /> Code INFO B a emitted I `SSerr Re uest# Invoice# Permit ID# <br /> cF2.7.Z SZ-f E1G ,�Cy�.cY1 1 <br /> S—C) <br /> 1?S./UJ Q7 Imo"y8 <br /> 41-01-001 ✓�}�la'f TGV- -L'10.0I ONSI A WA RMIT <br />