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APPLICATION FOR SANITATION PERMIT Pa it No. ..'1J3_P_�.
<br />ICemplere 3n D:pliute) Date Issued . /'I
<br />Apsliee'a is hereby ad, to fhe She J quip LamIH DM1 Disf,icf fox a pe,mif to Poisons& and install Me week Into, d will
<br />TA ppl f d pl & Counts O d N 549. 2� �OS�- 370 i ic+Ca.
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<br />Cmtm,a,e Name/:. zeOf- ._....._..... .........._... _____ Phone ____.._..._..
<br />1,0,11alim fll Residence LFIj Ap xh^ f H,i ❑ Co merciel ❑ Traile, Caen ❑ Motel ❑ Other ❑
<br />N tl "g nth: _j_..,N b ofbedmo ._L. N,mber of bath /_Lol six._
<br />Wehr Sepply: Peblic ai,wm ❑ Comm minty ePi,m ❑ P.ivefgA Depth to Wefm T,N, (D. O.
<br />C1amcfer of mal to a aapth of 3 Sew: Send ❑ G... In Sandy Leam ❑ Cley memo Cli Adbe ❑ Ho,dwn ❑
<br />eaAmss eppllmtto Made: Yes ❑ N,C4 New Con.fim ion: Yey)$I No ❑ FHA/ A. Yea ❑ NO C _-
<br />TYPE OF INSTALLATION AND SPECIFICATIONS:
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<br />)%at p4n showing an, of set,set,1 t of IndianaIndianan MN is wells, 6,111ah, can b IF[ aced wm III
<br />f0R DEPARTMENT USE ONLY
<br />APPLICATION ACCEPTED BY _ ... ....__..._.... ........ DATE.....
<br />BUILDING PERMIT ISSUED._._ _-___ _____ ____ DATE.
<br />Ai... an Oar r.aamm.na.emn. ._..._.. ..............1... ...._.11.1
<br />FINAL INSPECTION BY:..�!l.,.B�fy(rY._
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<br />SAN JOAOUIN LOCAL HEALTH DISTRICT
<br />110 Sent Jse.nic.a Stast
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