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<br /> FOR OFFICE,USE
<br /> A"LICATION FOR SAMAnON PERMIT FOR OFFICE USE.
<br /> Y" {Cemepleh in trlplicatel PermitNo....77`-7/G .: -
<br /> '�. Date Issued..l(. 77
<br /> This Permit Expires i Year From Date issued
<br /> Mppliaanon is hereby madii-o the San Joaquin Local Health District for a permit to construct and install the work herein described,,.
<br /> I 1his;applicahon is made in com01lance_with County Ordinance No.549 and existing Rules and Regulations., y
<br /> OF DD
<br /> KESS/LOCATION ;...................
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<br /> 4' lTa`'t�'�' CENSUS TRACT..............................7 `
<br /> 'Owner's Name ...............
<br /> Adciresi f
<br /> . COt1tr0 ter.�_�:. .,x �. 7r - �IaiQ►._ Phone.City..................
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<br /> Zip..., d
<br /> ctor s.Name....
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<br /> License #......................::.:..Phone: t fey,
<br /> r ilaHOn will�se ve , "..'..
<br /> Irtsta
<br /> Residence � Apartment House
<br /> ❑ Commercial(]
<br /> Num -Motel ❑
<br /> Other...::....::..:.:.
<br /> Trailer Court❑
<br /> bee of Irvin units
<br /> �,�� � �_ 95 Number of bedrooms.:..........Garbage Grinder.......___..Lot Size._..._..... 4
<br /> V.,
<br /> . . K.�
<br /> tit�
<br /> 'TWater...P ly:PublicSystem'aid name.:.:.._.::_' _
<br /> 'Chprocter ot.soll fo a de th of 3 feet _ Sand •-• . Private ❑ , i
<br /> y l r Hardpan❑ Adobe[] SFili❑Mater al© Pita
<br /> es Sandy Loam❑ Clay Loam❑ , v
<br /> Y}..type.....__
<br /> {Pick" Jan,showing`sizeEor lot, location of iysteiii in relation to wells,bvildings,,etc.must be placed on
<br /> Ns�r.INSTAlLATION ' (No septic tank or.seepage,pit perrnitted if ublic.sewer is avcifable wifhiri 200 feet,
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<br /> A1�E TREATMENT [ ] -,,SEPTIC-TANK l'] Size
<br /> Depth r>
<br /> Capacity ;TYPe a Materrai .... Compartmentr
<br /> nearesl:.WeR s
<br /> Foundation Prop Line v
<br /> CITING UNE3 ti ? :i� ;
<br /> ,NaM�of Lines length of each Une a . Total length
<br /> r -fs
<br /> Type Filter Material Depth Fillet MateNal `
<br /> DIstanoetc nearest Well Nu r '
<br /> foundation Property Line v�
<br /> SEEPAGErPIT �� y�y..-
<br /> �l,] ,� `� p . _Diameter Number r �- "wi n9t?'
<br /> y .l ry�V ` . s Rock Felled ,Yes❑ i Noi
<br /> , + w �IIlat�er.Ta61e Depth ,
<br /> Rock Size
<br /> ¢ 'ti Distance to nearest We11 r Foundation: f
<br /> t{, Prop line rN9
<br /> AQplT10N IPrevSanftation Permit#` I Dare sa
<br /> tfy Tvn`k-�VSPetify�Regtrirernentaj y
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<br /> . r r...a 1•: .n #
<br /> sa Fid(Spself a Refqulrerne
<br /> e,45
<br /> xishng and required addition on reverse side]
<br /> t1►°eerlify'that !w e+
<br /> prepared this applleatian and.that the work wlFl. be deaf'in:accerdon :L%,Ath Sam Jeegeln Caunly rMr
<br /> moss: Slate taw*, asid' ulee and Re ulatlens<ef the San Jos urn Ectal health Mittritt H;' a`n` er lices::o eiN,5
<br /> � •- .aerNdis_.�Ii Fold" }y `i r q
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<br /> q„6 M "P alas of,�i work'fier which this aiermlt Is issued;I shelf net employ ontr person in such mannwL as
<br /> pensciMon laws of CallEernia.. .y
<br /> `"'� � :�� �w _5��-�'2` y„T; '�•it '��
<br /> �w�4 lea+f k r �Titie.
<br /> �.,awi ; k�� f!f other than owners: - £ _• ,'
<br /> Fdfi'DEPARTMl1Nt�1JSE'ONEY'
<br /> n'APliLICATfON
<br /> ACC.EPTEb BY"F jj L: .' a t DATE 7 7 ~:
<br /> ;Df1�ISICIN OF LAND,NUMBERr "
<br /> 'AD 1 ITIONAL!; . .. , i G
<br /> b y COMMENTS ,. ;. .1 DATE
<br /> ' kn S„ u ice. T+.,!'-1�!^'• -3, 4 td•S4- r '- +.................................. �,}f
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<br /> r+��' .....17"� S.
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<br /> nal lnspeerion`byi :�.w ,. r: I
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<br /> ........................... .......... Date/.�
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 0`63214P7 snv,�!ra'aM;:.'-
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