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OWNER ADDRESS % 7 �Z/ �� �( J- CITY/STATE7LIP 7T""jq l � <br /> CONTRACTOR /-`I K-L Fu L L F—/e_ PHONE <br /> CONTRACTOR ADDRESS CT'/STATE/ZIP <br /> LICENSE ❑C-42 O C-36 OTHER NUMBER EXPIRATION DATE_ <br /> WATEp TABLE DEPTH:_ R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERCTEST(S) NUMBER LAND USEAPPLICA'FION# —� <br /> TYPE OF WORK: .,WNEW INSTALLATION ❑ REPAIRIADDITION O ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE; RESIDENCE LF*L'6/''=`-kc' MMERCIAL ❑ OTHER <br /> Iec NUMBER OF LIVING UNITS: NUMBEROF BEDROOMS: �2— NUMBP.ROFEMPLOYEES: <br /> wl SEPTICTANK TYPE/MFG CAPACITY (you gal #OFCOMPARTMEN'I'S <br /> ❑ GREASE TRAP TYPE/MFG_ CAPACITY 881 #OF COMPARTMENTS <br /> ' ❑ PKG TX PLANT DISTANCE TO NFAREST: WELL fl FOUNDATION R PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OP PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHINCCHAMBERS #OF LINES 2-- _ LENGTH OFLINES 8y R <br /> DISTANCE TO NEAREST WELL 11 FOUNDATION _R PROPERTY LINE R <br /> ' ❑ FILTER BED WIDTH tt LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION--ft PROPERTY LINE R IT <br /> ❑ MOUNDED WIDTH R LENGTH _It DEPTH R U <br /> DISTANCE TO NEAREST WELL R FOUNDATION_ R PROPERTY LINE R <br /> ' ❑ SUMPS WIDTH R LENGTH _ R DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R yr <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH it LENGTH R DEPTiI R �' <br /> DISTANCE TO NEAREST WELL R FOUNDATJON Il PROPERTY LINE fl < <br /> ti <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 /> r <br /> MINIMUM 24 HOAR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED Z� F CtiZI _ TITLE _ 0Yr` IA O'L-� DATE ,O <br /> Q7 <br /> l <br /> Ll <br /> / EI tE: <br /> A J NO IN <br /> 'OF LT P <br /> 0 J <br /> iZ <br /> ' 2 c <br /> DEPARTMENT USE ONLY <br /> APPHeation Accepted By Date 7-,f el(d"t Area "Z-f E Employee(O#_ <br /> Finallnspection By Date ? ❑ SPECIAL PERMIT-Approved by _ <br /> 'Character of Soil to Ptb 013 Ft: t�C El <br /> COMMENTS frlfd )ad- eFyw nl 4/0- Ci3L'ZZ-7 C' <br />