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APPLICATION FOR SANITATION PERMIT Permit No. 1 (Complete in Duplicate) Date Issued _•` Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------------ A-T rT�2 -! Owner's Name------------- �, ------ ----------------------------- Phone_f -- Address-------------- � eC .t.1 Contractor's Name --• ----------------- Phone----------------- Installation will serve: Residence ® Apartment Douse ❑ Commercial E] Trailer Court El Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms __I- Number of baths Z__-_ Lot size ---/-7, ------------•- Water Supply: Public system ❑ Community system E] Private & Depth to Water Table'�Z__Tf.-0 Character of soil to a depth of 3 feet: Sand p Gravel ❑ Sand Clay Loam El Clay [] AdobeX Hardpan Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well -.3d__- Distance from foundation__.__!?_.___._.Material__4!GF �c� �~ 19 No. of compartments-------- -----------Size--- .5(vSC-- _ -_ Liquid dep�h--------- -----------Capac,tY------�Q----- Disposal Field: Distance from nearest welt____ ---Distance from foundation ____ Distance to nearest lot line____ ----- Number of lines------------- ------------Length of each line-------- ----- -- Width of trench.--------- Al----- Type of filter material__ _____ ________Depth of filter material____.- --____----"_Total length--------------/wZr_Q - Seepage Pit: Distance to nearest well-_----------_---------Distance from foundation----------..........Distance to nearest lot line--- __ ❑ Number of pits_-------------------Lining material---------------------- Size: Diameter------------------,----Depth--------------------------------- --------_-_ Cesspool: Distance from nearest well________________ Distance from foundation--------------------Lining material_--____________ ------------------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity -------gals. Privy: Distance from nearest well_________________________ ______------___-----_Distance from nearest buildin ❑ Distance to nearest lot line Remodeling and/or repairing (describe)_______________________________________________ ---------------------------------------------------------------------------------------------•------------------------•----------•----------•--------.----------------------------------- ------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, S to w and rule sand reguI ti ns of the San Joaquin Local Health District. (Signed) ----- '' { _(Owner and/or Contractor) BY=---------------------••------------------------ (Title)-------------------------------------------------- ---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ---- ------------------ ------------------------------------ DATE------------- r4 ----------------- REVIEWED BY -------------- --------------- ----- - -------- ---------- ----------------••-------------------- DATE-=------------------•- -------------------- DIN PERMIT ISSUED ------ -- -•---- DATE -------------------------- Alterations and/or recommendations:_--.-_.__._-._ -------- ------ :.,.-. ✓ -m -------------------------- ----------------------------------------------------- ----------•------------------- ----------------------------------------------------- ••-------------•--------------- FINAL INSPECTION BY,,:;�� — �2: ` ........... Date---. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Souf6 American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12-54