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OWNER ADDRESS yrr�.�'� - ­r']r - 7 /-CrrY/STATEfZIPt/�c/q x5a1� <br />CONTRACTOR_ ��{ �O� ZL t,��� 1 T ��r ���. PHONE-�([{�I -ZS�Z /(tjl%/ - l32 <br />CONTRACTOR ADDIVESS 02011 '0, CiU-7-L-D AJG, -44- t :� CITYISTATE/ZIP L-Ot7L Ch- a'5 2 qo <br />LICENSE 9C-42 ❑C-36 OTHER NUMBER-75'?5­-i8 EXPIRATION DATE _0?-1z'g10A <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />N%W INSTALLATION <br />REPAIRIADDITION <br />1 ENGINEER DESIGNED IALTERNATIVE <br />REPLACEMENT <br />DESTRUCTION <br />INSTALLATION WILL <br />SERVE: RESIDENCE <br />❑ COMMERCIAL <br />OTHER <br />NUMBER OF LIVING <br />UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />O <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />9331 # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEARE.`'.•T: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE 1YPE OF PUMP <br />❑ PKG TX PLANT <br />_ <br />❑ $AND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS._ rr �# OF LINES <br />LENGTH OF LINEs��I. Qr ft <br />DL9' mm To NEAREST WELL IaO� <br />ft FOUNDATION <br />_� <br />L410t ft PROPERTY LINE 32 ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION _ <br />_ ft <br />It PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE To NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH _ <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL �ft <br />FOUNDATiON <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL H FOUNDATION ft PROPERTY LINE ft <br />Pd SEEPAGE PITS NUMBER 7- WIDTH ?JIo" ft DEPTH LS ` ft <br />DISTANCE TO NEAREST WELL I ft FOUNDATION 8c) If ft PROPERTY LINE r4Ql ft <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 LAWS AND RULES AND REIGULATIONS OF SAN JOAQUIN COUNTY. <br />INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (269) 953-7697 <br />SIGNED TITLE _ DATE a71Z�flS <br />DEPARTMENT USE ONLY <br />Application Ac -. <br />Date �— Area Employee ;D# <br />Final Inspection E _ ¢ t a_ Date 11SPECIAL PERMIT -Approved by <br />Character of So'l tp Dep of 3 Ft: PitfSump Soil Character: <br />COMMENTS <br />