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' OWNER NAME "TVi� C/O� �d�" '�'d `� PHONE y <br /> OWNER ADDRESS ,q CITYISTATEZIP /' / <br /> CONTRACTOR �V c �_ ()PHONE_ �i�'�►" 22 <br /> ' CONTRACTOR ADDRESSSZ2% CITY/STATEIZIP i(.J1�Q "i-cr, (:!;fl- t, <br /> LICENSE -42 Ll C-36 OTHER NUMBER STT'/ EXYIRATIONDATE o C7 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICA"CION 9 <br /> TYPE OF WORK: O NEW INSTALLATION ❑ ENGINF,ERPESIGNED/ALTERNATIVE• <br /> ' <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: A0.RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: 35 o� Nu METER OF EMPLOYF.F,S: <br /> W <br /> SEPTIC TANK TYPE/MFG 9 CAPACITY g-4l #f OF C0NSPARSMENTS 49 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITYgal NOF COMPARTMENTS <br /> O PKG TX PLANT DISTANCE TO NEAREST: WELL 0 — ft FOUNDATION ` ft PROPERTY LINE ft <br /> LIFT STAA7-ION St2E TYPE OF PUMP © SAND OIL SEPARATOR(ENCLOSED SYSTCM) � <br /> ALEACH LINES ,&_LEACHINC CHAMBERS / ##OF LINES qq, LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL --.�-1-.9..�—ft FOUNDATION �iJ ft PROPERTY LINE ,(-,O R <br /> ' ® FILTER BED WIDTH ft LENGTH P DEPTII ft <br /> DISTANCETo NEAREST WELL ft FOUNDATION ft PROPERTY LINE fi <br /> ® MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> ' DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ® SUMPS WIDTH ft LENGTH ;t DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ' ❑ DISPOSAL PONDS WIDTH ft LENGTH :2 DEPTII ft <br /> D9STANCE'I'ONEAREST WELL 1��� ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS WIDTH ft Lt � _ '7/J�. t DEPTH - Ct <br /> DISTANCE TO NEAREST WELL ft FOU DATION_ <br /> ft PROPERTY LINE ft <br /> II 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 REGULATIONS OF SAN JOAQUIN COUNTS'. <br /> 1MgAM k4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECT ?gS—PLEASE CALL.(204)953.7697 <br /> Q y <br /> SIGNED e TITLE_� —^� DATE ®A V <br /> 1 <br /> 75 <br /> Ile <br /> f <br /> S r 40 <br /> JI A <br /> DEPARTMENT U E ONLY <br /> Application Accepted '2�Bate Area Employee I <br /> ' <br /> Final Inspection Date��1 —2� �U,� ❑ SPECIAL PERMIT Approved by 7 <br /> Character of Soil to D th Df 3 Ft: PitlSump Soil Charaeter: <br /> COMMENTS <br /> i <br />