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FOR. OFFICE USE:
<br /> APPLICATION FOR SANITATION PERMIT
<br /> ---..,...................... Permit No.
<br /> lComplete in Triplicate) .............
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<br /> ... ... ................. ..... -----••---- ' ..,.. ._.. hr x}>!tre; r�ronj Da�e.I��aed
<br /> _ ....._. s 1?ermitE 1 Yeo
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<br /> A}ppli4atfor -is here)ar,,made'to•fhe-Sari-loaquin-'�6ccil-++oaith•Disfriet'�for a--permit--to "cor str 1"ate ihata�f tf,e vw+orlc" he #n
<br /> described. Thio apalicdtion,is rnado in com fiance ith Count 4rd'nan
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<br /> �N t re No. �i9 ' nd� xi •
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<br /> J B ADDRESS LOCATION ` y .....;......
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<br /> ddre�s ?�/U :' : I. :i:. :j:: i;... :i:...
<br /> ntrrictor';s Name' _.
<br /> City: ... . .. -- .. ...
<br /> ------ ----- ---------------- ------------•------......_._..-•--•-----....-•••-......:License
<br /> I 'stall. . ... : • .... ....
<br /> atiori wi8 seine= : Rei"sifeHce"[`]Aparfineril:Haifse ] Cori rrme'rciitI Ofrai er C,oe,rt; •
<br /> Nkatel` •.
<br /> Vurr►ber"•o# livrg emi#s :::::=:::::= Number of beeltoons :::.::_ Grrbae
<br /> ater.Supply--public.Systerm an'd.name.-
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<br /> a anter Qf sait taa depth of 3feeY , Sand ] SiltLj „Cfay Pte!
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<br /> trrl ,�dol�e
<br /> -. _. � Fit f Material ff des :-.•-:-
<br /> ( la#.-{sian,;-sho�nring sf;e•.o#•-lot ..locaticn Of•sysfem in-#elatlort•io•vveilst"bufidings, i
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<br /> ....ete...'mt►a�t-.be...pldced-•ort='reverse':s .)
<br /> lV.f,NSTAi.i.I,TION:,...;..(Nd_sep#ic._tank ot-.sieePr ge... it. err itted.if.p�rb*.z6wer„is.ov:a8clble.'Within 2l10.feetj �
<br /> .. :. .]i...SEPTIC•TANK.1s.]..... ....... .......i....._�ize,�:::.:::�::: --- ..: I:I. �lt�..
<br /> P GKAGE TREATMENT :_[
<br /> t �, PBA ..
<br /> Capacify : • ,• :- - Type'; _ Material- No.: Corn ctirtmonts —! #
<br /> . ... ::::............... .{...P..,......int �
<br /> Dis3ance to neprest: Well Founddtior�--- Ptop. Line .. - .,t'
<br /> L ACHING:LIN a, of'lines ' ......... Length of vack fine -- T'atal Lehgth
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<br /> .D':Sa> ...
<br /> T. ,e.
<br /> Filter;Material ... Death Fil ... _ i
<br /> YP for AAiaterl
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<br /> I3 s dheO” o-nedrest:'1Nc l }:._. F rid-fio -
<br /> +----- u Q rj p'rapeity' ll;ne .. ..
<br /> S EPAGE PiT. . ..1.. Depth .: ''::::,::: ' Diameter.. li3nnfer...................... ::: w.
<br /> kodc Filhed •:.1� 'd... 1�0
<br /> Water--Table-�De .. . .. .. .. ... -- . . ... ... . ,., _..
<br /> .. ._ _.. ._,. . . p - - -- :hock•&ire••::i __:: � �
<br /> �.. ,_...... -;Distancq..to,i�ear',est:.Well..----a•�..�_.. .�.�.,,....w...,,.;.Foundati !:•:'-::•:-' -�:�: '•:.:,.. .,.. ._.; E-.. � t
<br /> It4FAIR/Ad0lTi=ON lPrev. Scr. ita ion,l?ern it•!#, .- ` I _ w
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<br /> Se tic T'n
<br /> k S e i Re ,
<br /> � t a rem$nts
<br /> sal; Field sD.;spo I (Specify fiequirerrien#s) ...... .a .- '�? -�' r� E - -- --
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<br /> 3(DravV ex�stir g•a►d•r qvi�ed c#di#ior�•pr►•r8verse sitfe]..;.....- ... ....'
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<br /> ere y c rtr that ! have re ar�d this dppll atidn a
<br /> ....Q... !....,..,...... ..........p....P ...PO4 hd tha"he work-v�ili 16 gone; in jaccoro ice �o Joaqu n
<br /> C unty' Ordinances: State Lows; ant! Rules dncl*egylations of th® Sion .loaquin �oca� Hejolth ©is ric#. Horns oWneir or ifice
<br /> s ;agents'signature cetfifie's•the-folibwie►g:..;...,. ; ., t..._...;...... ... .. ... ... ... ...
<br /> that i' th'
<br /> "I certify, e:_ or ; am{e of;thework four wl}tch phis emit i# tssoed,';1-sFfp11- et- x x
<br /> t .. ...� .. ersem. ..xucl!t."Wan”
<br /> a to become subiett to Workman's:'Conipen'satien laws of Clalif4m14,"
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<br /> It?EPARTMENT USE ONLY1.
<br /> A PLICATION AccEPT8D 8Y
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<br /> B tl�iNG`"'F'ER1'iT"°#5S1JED" ._� _, .. .,
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<br /> A DITIONAL COMMENTS ------ - -
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<br /> �K -
<br /> Final inspection by: _.._.._.. ..-Date c ._'— 7`tj.----------
<br /> EH ! --
<br /> 13 2 3-68 itev. 5mSAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M I
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