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OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR w-\ �C^ 1�J a�f�� <br /> �GeLA '1�1�t PHONE GU I <br /> CONTRACTOR ADDRESS t I S .T����e�. �� CITYISTATEJZIP - cct C ti <br /> LICENSE _C42 i,7C-36 OTHER NUMBER (Z 1 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED!ALTERNATIVE <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL L OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> O SEPTIC TANK TYPEiMFG CAPACITY gal #OF COMPARTMENTS <br /> 0 GREASE TRAP TYPEIMFG __ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPER-"LINE ft <br /> C] LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL_6 J, f ft FOUNDATION _ ft PROPERTY LINE ft <br /> O FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ® MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNQ TION ft PROPERTY LINE ft <br /> SUMPS WIDTH DIY ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL10' ft FOUNDATION ft PROPERTY LINE ft <br /> O DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION R PROPERTY LINE ft <br /> 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED V l TITLE y\k,"" DATE 1( i- <br /> T I <br /> —217 <br /> IMES 471 <br /> I <br /> 0 <br /> EPARTMENT-O 'Y- - :TI- 7raAzT rr¢/ <br /> r. riicaticn Acce _ Date_ Area Employee IG# q"! <br /> Final Inspection Date SPECIAL PERMIT-Approveo by <br /> Character of So,l t Depth of 3 Ft:__ PiUSump Soil Character _ <br /> ;- M M E N TSl� <br />