Laserfiche WebLink
' �' L ti f� ISA n! 11 1 n PHONE <br /> OWNER NAME nn c /� <br /> r. L e"C D I E n It. CITYISTATE121P FLS CALM .C,}. 9 <br /> tAftttER lk <br /> 0fSWS <br /> ' GbNTRAGTOR' S A � PHONE <br /> CONTRACTOR ADDRESS CITYfSTATEIZIP <br /> ' LICENSE QC-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: <br /> ft GEOGRAPHICAL INFORMATION: COOrdinatOS X Y <br /> ❑ PERC TES # <br /> IADDrnON <br /> BUILDING PERMIT#. ! LAND USE APPLICATION <br /> T # <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR <br /> ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTIONS <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: <br /> NUMBER OF BEDROOMS: Yn{I7 NUMBER OF EMPLOYEES: �Z <br /> 11 <br /> SEPTIC TANK TYPE/MFG CAPACITY I20� gal #OFCOMPARTMENTS 2 <br /> 1l � LQL�L'G <br /> 0 GREASETRAP TYPEIMFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br /> M LIFT STATION SIZE TYPEOFPUMP O PKGTXPLANT O SAND OIL SEPARATOR(ENCLOSED SYS y�y <br /> LEACH LINES El LEACHING CHAMBERS #OFLINES NGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION OY ft PROPERTY LINE ��7 It <br /> O FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ;ft <br /> 13 MOUNDED WIDTH ft LENGTH it DEPTH i ft. <br /> DISTANCE TO NEARS T 1 ELL ft FOUND ON ft P PERTY LP(E I ft <br /> yY- SUMPS WIDTH�ft LENGTH R DEPT ft <br /> DISTANCE TO EARS WELL '� ft FO DATION ft OPERTY � � 'r ft •• <br /> O DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST AWEIIL ft FOUNDATION ft PROPERTY LINE .I ft, <br /> O SEEPAGE PITS NUMBER WIDTH <br /> It DEPTH <br /> DISTANCE TO NEAREST WELL 'ft FOUNDATION <br /> ft PROPERTY LINE I 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 /> JMINI (�jjM 24 H9U DVArgCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209}953.7697 <br /> SIGN EDA�l•f=-��.-I TITLE DATE <br /> 1 ` <br /> ' t <br /> PAYME T <br /> rd CE <br /> '`. <br /> tj <br /> R` <br /> J x o UImr <br /> ' Y <br /> I <br /> 1 I <br /> 1 , Dg ARTMENT SE ONLY <br /> ;pPump <br /> (� A Employee ID# <br /> - •.,gppliaetbn"Aeeepted _ .Final inspection By ate ❑ SPECIAL PERMR•Approved byI <br /> Character ofSOU to Of 3 Ft:- oll Character <br /> COMMENTS <br /> es ilt ? <br /> 1 CnA- o(I; <br /> Permit/ � <br /> PE C Received Am of Invoice# Permit lD# <br /> f:evfo INFO By h Remitted Date Service Request# <br />