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OWNERNAME CKV a� N �y ADDRESS Zoog <br /> CITY/ZIP ✓A��' <br /> 4?1 . filY� � 'r6 PHONE NUMBER <br /> CONTRACTOR/1O .�r1 .-LS�►.Py�Ty •� ( ADDRESS -`353"ySofcE.ri•�fHaVl[:Y�I {Q/01. 1 c} <br /> ' CITY/ZIP OQ 4W �+ter% L/�. f�'�,J� PHONE NUMBER � `���T�•^� /�/'T�'��1� <br /> GEOGRAPHICAL INFORMATION: COORDINATES. X Y TOWNSHIP-RANGE-SECTION- <br /> TYPE <br /> OWNSHIPRANGESECTIONTYPE OF SEPTIC WORK- INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> KNEW INSTALLATION A RESIDENCE NUMBER OF BEDROOMS: <br /> ❑ REPAIR/ADDITION ❑ COMMERCIAL <br /> 1 <br /> ❑ DESTRUCTION ❑ OTHER NUMBER OF EMPLOYEES: <br /> ❑ ENGINEEREWALTERNATIVE <br /> CHARACTER OF SOIL TO DEPTH OF V: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> CIQ <br /> BI PERCTEST(S) HOW MANY APPLICATION# <br /> ❑ 'SEPTK:TANK TYPE/MFG CAPACITY #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY #OFCOMPARTMENTS <br /> ' ❑ PKGTX PLANT DISTANCETONEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ LIFTSTATION SIZE TYPEOFTUMP SAND OI L SEPARATOR(ENCLOSED SYSTEM) ,111 <br /> ❑ LEACH LINE <br /> #GF LINES: LENGTH OF LINES: MWANCETONEARETT: WELL FOUNDATION 'PROPERTY LINE <br /> INFLITRATOR CHAMBERS: <br /> ❑ FILTER BED WIDTH LENGTH_ DEPTH- DWANCETONEARETT: WELL_ FOUNDATION PROPERTY LINE_ <br /> ' ❑ MOUNDED WIDTH LENGTH- DEPTH= UWAN IITONURER: WELL FOUNDATION PROPERTY LINE, <br /> LJ sumps WIDTN LENGTH DEPTH DWAMETONEARETT: WELL FOUNDATION PROPERTY LINE_ Q\` <br /> ❑ DISPOSAL PONDS WIDTH LENGTH_ DEPTH DLttANCETONEARLM WELL FOUNDATION PROPERTYLINE <br /> ' ❑ SEEPAGE PITS # DIAMETER DEPTH_ DMANCETONEAREAT. WELL FOUNDATION PROPERTY LINE <br /> - <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS <br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ' MUM 24 R NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)468-3423 <br /> SIGNED: TITLE: IVIL Il/�rDATE: <br /> i <br /> i C- <br /> ' _ --701-1 <br /> WNXAQUN elU _ _ <br /> N EHAL- <br /> H " i DE PR VEN <br /> + I <br /> I <br /> i <br /> �....,.. ... __-_ _._ EPARTMENT. E LY.. <br /> APPLICATION AME <br /> ■ �I`� DATE: ARE'A aaaEMPLOYEE IDM DISrtUC J-LOCATION <br /> ' INSPECTED BY: DATE /tTJ//f•J PERMIT FINAIU�CAYES DATEI/1$1[D INSPECTOR: c� <br /> COMMENTS:ILJD• T-�I� '•+/�•'/ /O " G .] <br />