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OWNER ADDRESS CITYISTATEIZIP <br /> ' CONTRACTOR al /♦ / C�G'1/./l7 J!leI` �, � a PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> ' LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE I COMMERCIAL ❑ OTHER too <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: L <br /> ❑ SEPTICTANK TYPE/MFGCAPACITY gal #OF COMPARTMENTS (, <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS �lJ <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> O MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE To NEAREST WELL R FO DATION J R PROPERTY L`E ft <br /> /VJI SUMPS WIDTH R LENGTH I ft DEPTH $ ft <br /> ✓ DISTANCE TO NEAREST WELLf tw ft FOUNDATION If ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ' 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 5�11M NIM 4 HOU ADVANCE NOTICE.REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED � ��!/ TITLE CA.1h ow DATE <br /> 1' <br /> r <br /> G g O/Q N O N <br /> i E VI <br /> A4 J <br /> la <br /> /ti R <br /> i 1 <br /> - DEPARTMENT U.' ON / <br /> Application Accepted By Date Z Area Employee ID# '( <br /> ca . <br /> Final Inspection By _ - Dr,to l ❑ SPECIAL PERMIT-Approved by <br /> 1 Character of Soil to Depth o -�/ APittSump Soil Character: <br /> COMMENTS ARSI- �kei ,1 I/i. .. s"o-t IM QTY,.. PlAl. /Biu O vGyi0 r v .: 'ari <br />