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OWNER NATE t - <br /> C ITYISTATEIZIP <br /> OWNER ADDRESS <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS /p CITYISTATEIZIP <br /> .0-36 OTHER NUMBER DyS EXPIRATIONDATE <br /> LICENSE A-42 <br /> --WATER TABLE DEPTH: <br /> ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> FERC TEST # BUILDING PERMIT#, LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEWEW DATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> O REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM Q DESTRUCTION 1 <br /> 1 STN ALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 0 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG L L CAPACITY 14410 gal #OF COMPARTMENTS z- <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENT�S-y� <br /> DISTANCE TO NEAREST: WELL , ft FOUNDATION ( , ft PROPERTY LINE aV ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP LJ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES I& LEACHING CHAMBERS_ #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL fOsr , ft FOUNDATION ✓ift PROPERTY LINE S It <br /> O FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> U MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft i <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH <br /> ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> SEEPAGE PITS NUMBER t WIDTH_ 3 ft DEPTH a'g ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE + ft <br /> I HEREBY CERTIFY THAT 1 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 TITLE �� DATE <br /> JV <br /> Ix <br /> VV <br /> IL <br /> 1 � <br /> E P,A4 -TME"- - S 1V L.Y .SAW50A'QU N COUN f 6" <br /> Application Accepted B Date Area � E <br /> LTH Da aF RfMG I <br /> Final Inspection B Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soll to De)A of 3 Ft: PitlSump Soil Character: <br /> COMMENTS ������ �t//i/�L� !E t GLIO�P - <br /> C"GYL ��Zi1J <br />