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OWNER ADDRESS �V �L.IY 7 'LII 1VI J CITY'ISTATEIZIPLT •K�[7 LSI�'� / 5Z t <br /> CONTRACTOR �T(YI�I.Y PHONE .\ <br /> CONTRACTOR ADDRESS CITVISTATEJZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER .NUMBER E`/ EXPIRATION DATE V <br /> WATER TABLE DEPTH:_ fl GEOGRAPHICAL INFORMATION: Coordinates X Y /V <br /> ❑ PERCTEST(S) NUMBER _ LANDUSEAPPLICATION# J <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITIO,pNl CIENGINEERDESIGNEDIALTERNATIVE <br /> ^ / <br /> ❑ REPLACEMENT DESTRUCTION I�nJ <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER_ <br /> NUMBER OF LIVING UNITS: N LIMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFGCAPArn-Y gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPVMFG_ CAPACITY gal #OF COMPARTMENTS <br /> ' ❑ PKG TX PLAINT DISTANCE TONEAR": WELL ft FOUNDATION II PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE.OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ' ❑ LEACH LINES ❑ LEACHING CHAMBERS It OF LINES _ LENGTH OF LINES <br /> DISTANCETONEAREST WELL K FOUNDATION _Il PROPERTY LINE fl <br /> ' ❑ FILTER BED WIDTH _ft LENGTH ft DEPOI ft <br /> DISTANCE TO NEAREST WELL ft FOUNDAIIUN ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH ft LENGTH _Il DEPTH R <br /> DISI'ANCF.TO NEAREST WELL ft FOUNDANON_ _fl PROPERTY LINE ft <br /> ' ❑ SUMPS WIDTH II LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE H <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH _ ft DEPTH_ it <br /> DISTANCE TO NEAREST WELL ft FOUNDAT:ON it PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH Il LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION fl PROPERTY LINE It <br /> ' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAW'S AND RULES AND REGULATIONS OF SAN JOAQCIN COUNTY. <br /> MM LIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION -PLEASE CALL(-109:1953-7697 �7 �} <br /> SIGNED R•'a'n,�f !T/'L/ '-� TITLE_e�'7'J LIZ{!N DATE 2- / V <br /> 17R1 a1 <br /> 1 <br /> I N i wi 1 <br /> n 1 <br /> j ♦♦� ; j 1 io i -*&nt1r •1 l 'k { ~ Zz / I•� =. V <br /> 1 ° 1 <br /> 1 1 1 <br /> DEPARTMENT USE ONLY , / <br /> Application Accepted P.y 4 Date L. 9 C�_ Area -2 / L' Employee ID#_ / 4s& <br /> Sh <br /> Final Inspection By K Date ❑ SPECIAL PERMIT-Approvedby _ <br /> Character of Soil to pth of 3 Ft: T�� � Pit/Sump Soil Character: <br /> 'COMMENTS /i. - o ft /;�p N / [ R--t- i✓Pi�is� / y� i /1t =- ,rte c / A <br /> r--. i <br />