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OWNER NAME I\fl J ffy d/� f11 J f7 i..]��.I . C .� _ �•''ar�mmyy� .�. - ,.,t- pL��--�-T U <br /> OWNER ADDRESS <br /> � — <br /> 3-_^3-y-ya--1-5'F�-�� ��"/�` CITY/STATE21P <br /> t - CONTRACTOR^_- PHONE <br /> CONTRACTOR ADDRESS CITY/STATEZP <br /> LICENSE QC-42 4C-36 OTHER NUMBER EXPIRATION DATE <br /> 1 WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION /+ REPAIR/ADDITION ❑ tNGINEER DESIGNED!ALTERNATIVE <br /> 3 ❑ REPLACEMENT ❑ OUT-OF�SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ' O SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> O GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPFRTY LINE ft <br /> O LIFT STATION SIZE TYPEOFPUMP O PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> V <br /> O LEACH LINES 0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES fl C <br /> tDISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It <br /> O FILTERBED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE •ft <br /> O MOUNDED WIDTH It LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft t� <br /> O SUMPS Worm It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft j <br /> O DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY UNE ft <br /> ' O SEEPAGE PITS NUMBER WIDTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION It - PROPERTYLINE It <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 /> MINIM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS a PLEASE CALL:(2091953-7497 <br /> SIGNED I � )---i <br /> .__ <br /> p��R7..ryyEM�C/� d <br /> s <br /> fNC250N7Y .f r <br /> ENVIROtYNIENTAi <br /> - <br /> 1 ! <br /> i` <br /> _ 1 <br /> ,. ,. Fs%i5' t�+ 6'GAtiN a tr <br /> . .. f.... .. ` <br /> 1 .. - - <br /> - . <br /> - .°r... "...:�.z � .- ..--0'EPARTMEN7U E ii'L'.,. -- ^.c --..._.. . <br /> r Application Accepted By Date f t Area Employee ID# �J <br /> Final Inspection By ate '01-2-11.1 ❑ SPECIAL PERMIT-Approved by <br /> Character Of Soil to Elfapth of 3 Ft: Pi Sump Soli Character: <br /> COMMENTS AFI!-,n rt= JCrd �EJJ�+itF�r< T �OA �Tt.ac ToLY'tcc +c6rn+6 i�M CrE.sE <br /> 944e 7-0 e. ✓ CA-a/,00, .(r OF SSE La,--JE <br /> ' a�i`=1t `r.°t - tkDt.uSrJV& CTtSE 00003315( — SE.E � AIEroGE &ye-V6T017- <br /> oc cr Ioe,.w..e.• III oe....:•r <br />