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FOR OFFICE USE: <br /> APPLICATION'FOUR.SAM,', �.ioN PER.pjrr <br /> (CmwplM0lot 7rfpiiewell Na G <br /> • <br /> Wnni1 C <br /> F r"�i r This Permit Expires 1 lreor Prem De»e Issac�" Dote faeuied / m <br /> Application is hereby made to the Son Joaquin,Local Health District fora $Y <br /> permit to camshvd and rn <br /> a described:This,application is made in compliance with County Ordinance No. 549 andM. <br /> nclstiny Rues <br /> JOB ADDRESS/LOCAT'ON AC — <br /> �j <br /> ' Owner's Nam <br /> e ._. <br /> "Address <br /> tar A,i. _-.._.... �y�,,. ,t:-lC� v�".M......�:-i,� � � <br /> : .. ....'�1 � i <br /> Contractoi'S NQMe ........ ...................:...-..'�dntl# <br /> ;s a installation wits serve Residence�Apartrttent House❑ Commerc3al�Trr.''ar Court =j <br /> t a.' <br /> J"Nu '�f �-4 13�f Motel❑Other <br /> / <br /> r ofving un+ts:..l..._...- Number of bedrooms ............,Garbage Grinder..... Lot Size .... `.. <br /> Water Supply: Public System and name <br /> C narcv-ter of soil to a depth of 3 feett Sand T j Silt❑ day ❑ Paut❑ Sa }y loam[j Cly Loan►❑ <br /> ' z <br /> Hardpan❑ Adobe❑ Fill Materlol........ P' y.s,type <br /> h '' ,% (PIo1 �► tF inq' size'cf lot, foentlon of :)rstem in nikon to wells, buildings, sic. must be plaid on rvvW s(d J <br /> "` Of : (No sept(c tank or seepage pit ptrrrnittrd if public sower is r vollabie within 200 f 0.0, <br /> ao ./. -'11.Z '. ........ liquk9 Depth <br /> 4f �` r,,Capadty �c � Typkxeri� �iMater tol. ric:4"r Ne. Com�par"in' tai <br /> Distance to nearest. Well =:....... ..... ..Voundatie t -�U Prop,Urm <br /> L NE'= ( j No. of tines Length of each I(grt. L%. ::_ Total lerth <br /> f 25'• g �i <br /> D' Box .:..:. Type Filter Moferiolfll .�.�u« l^tfi Fit:-7 Mcf*rial_.._.�"�-�� rA <br /> `p ix L Distance to nearest: Weii 5z....... Foundation .::.J`!" Property"Llne . ;i-f- <br /> s; I. P •f . Rod' F:Iled Yr <br /> Depth .... ..l�.-...... �Lamuttr 'y,r�� Number :.....�- <br /> Water Table Depth ��:' Rade Size is Y <br /> Distance to nearest: Well :5 ................ ......Foundation. ./.r-. _.._... Prop.'UM . <br /> RETAIR/ADDITIdV(Prnv, Sanitation Permit# . .: ......-- Dat* r...._... _........ . .I <br /> MACk*Tank"ISpecify kequirements) ........-:...... ... .:... ..... ...... ...... .._.._... ---- , -... ._:..:... _.. <br /> '��; 7 i / <br /> r. ;� lsposal Field (Specify Req, rements) --..�.� �"� / y� �S l� l s`�-r<: ��c.fid? .sa��'/•� <br /> " 0ta �li ` <br /> ------------- <br /> e <br /> �rp a (Draw existing and required addition on reverse -sde) <br /> w <br /> cerfiw thnt i have prepared this application and.that Mist work will be '",ene in aaerdmu tvitls Sass 'Jee�t�M <br /> County Ordinances, Stats laws, and Rules enc! Regulations of the San Joaquin Lecc l Health DisMct.Home ewnw or Neese' <br /> sed agentr signature certifies the following: <br /> "I certify..that in the performance of;the work for which this permit is issued, I sholl not employ any person In suds sssaesserr <br /> _aim become UNIF t to s Compere atierr laws of California."",, <br /> 5tgned%Ia 'c "'` Owner <br /> � � y,�+!`N a ,.. �eye :�j. �'x,,:• :....._ �- : .. . . . ..... . .. - 7irle . . ... . ..,.. _ <br /> j y <br /> 'IIf Omer than owner) <br /> r x , <br /> FOR�tPART ENT USE ONLY <br /> rN' 'i lel, <br /> r r APP,CICA7IONIACCEPTED BY, _ DATE f- -/� el, -- <br /> T i ! BIiILtSINGkPU.AlT:;ISSUED � ..._ ` / .... ........ . ::...... .. . . . ;..,.Dt'TE <br /> Aq,DD�irr�1�O�N�i��COMMENTS J . <br /> �;yet P 'x����' mal ir, pectYon by •' -/_ Doty <br /> 2L --6;1, tnv: ,�'t � N JOA. 'JI'J,LOCAL HEALTH DISTRICT <br /> I <br />