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OWNER NAME �\nC �/JPGH !77 V_I�JS PHONE Z05 <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR PHONE J65':�OZ7 <br /> CONTRACTOR ADDRESS 0A(m° I>YZ- CITY/STATBZIP _/��•. <br /> ' LICENSE ❑C-42 [7C-36 OTHER NUMBER EXPIRATION DAT <br /> WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ' ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: D NEW INSTALLATION REPAIRIADDITION D ENGINEER DESIGNED/ALTERNATIVE <br /> J REPLACEMENT ❑ DESTRUCTION <br /> ' INSTALLATION WILL SERVE: 'RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: /�� NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> . SEPTIC TANK TYPE/MFG 2�JC/S�auS CAPACITY )4cc7al #OFCOMPARTMENTS ` <br /> ' I] GREASETRAP TYPE/MFG /CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL /If FOUNDATION It PROPERTY LINE ft <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP i ❑ PKGTXPLANT SAN OIL SEPARATOR(ENCLOSED S STEM) <br /> ' LEACH LINES LEACHING CHAMBERS #OFLWEs LENGTHOFLINES O ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPER LINE ft <br /> ❑ FILTER BED WIDTH R .\LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL\ it FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft ENGTHft DEPTH ft <br /> DISTANCE NEAREST ft FOUNE ION Zip ft,. PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft NG It 'DEPTH ft <br /> DISTANCE TO NEAR LL ft F dDATION Gb ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH N DEPTH ft <br /> ' DISTANCE TO NEAREST LL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE 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 REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> �-PLEASE CALL(209)963-7697 <br /> SIGNED TITLE DATE <br /> 1 <br /> o <br /> 1 <br /> 7 <br /> 1 <br /> A <br /> ' IE <br /> 1 SiO UN O N <br /> TY <br /> ° IC [v H E <br /> LffT <br /> ' <br /> DEPARTMENJ YSE O Y <br /> Application Acceptetl D to L- Area Employee ID# <br /> Final Inspection By, e -9/3r) L El SPECIAL PERMIT-Approved by I <br /> Character of Soil toElapth of 3 Ft: VittSump Soil Character: <br /> ' COMMENTS t-'XiQ 1A7F /71 42E��� <br /> �C� viw�� ri�i Sr✓l�°��iY <br />