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OWNENADDRESS ✓ �`f•,�' �VJf f LJ CITYISTATE/Z1P M� 3I <br /> CONTRACTOR �+/1/Wf' N /lL3eu PHONE "" <br /> CONTRACTOR ADDRESS CITYISTATEQIP <br /> LICENSE. ❑C42 ❑C-36 OTHEK NU,MBEN E%PIRATION DATE_ n <br /> WATER TABI.F.DEPTH:_ fl GEOGRAPHICALINFORMATION! CDardiRatea X Y ") <br /> ❑ PERC TEST(S) NL MUER _ LAND USE APPLICATIONH e, ) <br /> ' TYPE OF WORK: NEW INSTALLATION 13 REPAIR/ADDITION 11ENGINEER DESIGN'EDIAITERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER_ 'j, <br /> NUM ER OF LIVING UNITS:_�(f /1 y NUMBEROF EDROOMS: �7�y-� NUMBER OF EMPLOYEES: Q <br /> SEPT CTANK TYPE/MFG A ` I���I CAPACITY y-9/!/1 j gal 40FCOMPARTMENTS <br /> GREA E TRAP TYPEIMFG(jQ�C'Ulby CAPACITY / [) gal H OF COMPARTMENTS <br /> e—� <br /> ❑ PKC TX PLAN-I' DISTANCE TO NEARF.aI': WELL H FOUNDATION @ PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACH LINES ❑ LEACHING CHAMBERS HOF LINES _ LENGTH OFLIVFS <br /> � DISTANCETONEAREST WELL H FOUNDATION _11 PROPERTY LINE It <br /> ',}Q(FILTERBED WIDTH 30 R LENGTH �D H DEPTH �' -5 R <br /> � DISTANCE TO NEAREST WELL 2Go_ H FOUNDATION /�j��_B PROPERTY LINE_ ti <br /> ❑ MOUNDED WIDTH H LENGTH _ _H DEPTH f1 <br /> DISTANCE TO NEAREST WELL R FOUNDATION_ n PROPERTY LINE ft <br /> ' ❑ SUMPS WIDTH R LENGTH - II DEPTH fl <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE tt <br /> ❑ DISPOSAL PONDS WIDTH fl LENGTH _ it DEPTH }t <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH D LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL it FOUNDATION R PROPERTY LINE. R <br /> ' I HE R EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BF.DONE I N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. <br /> q STATE LAWS AND RULES AND REGULATIONS OF SA N JOAQWN COUNTY. <br /> (r MINIMUM 2e HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-P1 ASE ALL(219)953-7697 <br /> SIGNEDTITLE /rjl! DATE O <br /> 1 I 1 1lA9l3A0 <br /> I I <br /> I co,4Rs r ,� <br /> 1 I I YI dLPARCINGyD '; SS . <br /> I]J� <br /> ^%iBTr{G <br /> lNYIP 1 <br /> 1 1 <br /> c_T <br /> ' <br /> —;,Yl GCEd9E N cRCEPCR TANG 1 I <br /> 1 I. I j I'J PRnPtblD 1 <br /> 1 li 1 1 f PIIILDr'IG Cal PAYED TARD 1 \ <br /> AND CT'ROKNENTE <br /> CA <br /> p I` <br /> 1 �� � j � ,-,„1�" �•F� <br /> EkIETMb <br /> II '• <br /> 1 au .....I 1 I <br /> 1 ,• 11111,,`.>'�'.1 r �FENCeD LiT GTA'IM-1.....-- .. 1 <br /> i L \ I I I I�FxUn <br /> 1 I 111 ..• 1A _ ExIGfiNG a .. .,.«IX s-Den OR...... <br /> 1 I' I 11 <br /> • I 1 sudr,E ` <br /> —�1/jI 1 <br /> cc <br /> I IiCRAGE <br /> I In 1 :. j I I I _ a E2N1TYG4TNlS 1 c <br /> 'i Is,AD PAYED olajf A,� --_'�- 9TRIPPAG WPdaEnESJ� ' 1 <br /> 1 <br /> 1 I <br /> l <br /> I <br /> s <br /> 'Application Accepted DyDrle_-1�� Arca til 4(,?� Employee IDo <br /> Final Inspection By _ Dalc 2�J �,� ❑ SPECIAL-PERMIT-Approved by _ 7 <br /> Character of Soil to&pth of Ft-' Pll/Sump Soil Character: <br /> COMMENTS -o=1 t.4al AeA;r � !� . /. /OL�(/y � <t �+✓ l�b� w_r� r Y , �i�, CCT <br /> . . . -----rte <br />