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OWNER ADDRESS PO� O 8-Ox /--234/& CITY/STATFJZIP � /^�OA 53777 <br /> Dew CJ/ e/z�661ex ,I PH/ /'A ONE/ <br /> CONTRACTOR ADDRESS /(�`�- 42. ox Z 247 T CITY/STATE/ZIP LU CEe ` <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE, <br /> WATER TABLE DEPTH:_ .9-0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y (1� <br /> PERC TEST(S) NJMHER I LAND USE APPLICATION# 1 <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT O DESTRUCTION <br /> INSTALLATION WILL SERVE:— ❑ RESIDENCE COMMERCIAL 13 OTHER_ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPFJMFG_ CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPFJMFG_ CAPACITY gal #OF COMPARTMENTS O <br /> , ❑ PKG TX PLANT DISTANCETONEAREST: WELL R FOUNDATION ft PROPERTY LINE fl <br /> ❑ LIFTSTATION SIZE. TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINER ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION fl PROPERTY LINE ft <br /> , ❑ FILTER BED WIDTH ft LENGTH 11 DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION it PROPERTY LINE <br /> ❑ MOUNDED WIDTH it LENGTH _ft DEPTH H �fC <br /> DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH _ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ' ❑ SEEPAGE PITS WIDTH it LENGTH R DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQU IN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> it r 2e HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE &JAI✓6:Q DATE (I" 27` C73 <br /> ` ' <br /> Al I <br /> I <br /> T C <br /> U e <br /> At <br /> All 11 <br /> 1 C. N <br /> LI HE LTI SEF <br /> DEPARTME T� E OVkY <br /> 'Application Accepted By -i Date 1 Area Employee ID#_C.✓ <br /> Final Inspection By �`��^N Date Z'O ❑ SPECIAL ERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pf/Sump Sall Character;J <br /> ,COMMENTS MAS d 3 n JO LTJ D{g�RW�ea Y�1YGf <br />