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FOR OFFICE USF <br /> APPLICATION FOR SANITATION PERMIT <br /> ieemplete In Trs'plkele) Permit No, 7S..sem....-. <br /> _ '2,a,L y I TMs Penw)t E=liras 1 Peer Fran DoN issue! -Datelssued <br /> LjA licorion-s i+ereby� r �� t f 2�( - 0"--7/ <br /> PP oaqu.n Local Health Disn.ct for o permit to construct and install the work htireirt <br /> described This application it made in compliance with County CkdMonce No. 540 and existing Rules and RisgaIMiOM, <br /> log ADDRESS/LOCATION ?YJ�pOrrgj:� j'S �ih�d '.d - CENSUS TRACT .. _ ...... <br /> Owner's Nome A tia Phone <br /> Address �0' Ae& y 1;0'4 .51 iii city <br /> Contractor s Nome L+renta III Phone �ed :z.,rf.. <br /> installation will serve: Residence a Apartment House rj Commercial OTroiler Coo" ❑7 <br /> I Motel r`Oilier <br /> Numbef of I-vinq units: if 1`4v bet of bedrooms Zj ..Gwboge Grinder Aolav, Lot Site <br /> Water SvpPiy: Public System and name . .. . ._....... Privote,� <br /> Charocter of sod to o depth of 3 leer Sand C Silt Clay ❑ Peat® Sandy Loam X Clay Loom ❑ <br /> Hardpan❑ Adobe C] Fill Material if yes, rypa <br /> Met pion. thawing sire of lot, location of system in rotation to wells, buildings, are. must be Placed an reverse fide.) t <br /> N1W INSTALLATION, iNo septic rank or seepage Pit Permitted if public,sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I I SEPTIC TANK PC Size AIXQtC tiquid Depth 1 I <br /> D sponte t/1.00 r: Well Material s No- Comportments 'L ..... . <br /> _ 6 <br /> 8 J-r owsdat ort /fi' Prop L+se <br /> f <br /> LEACHING LINE ( ! Noof lines / Length-of e�acch`l1wee- 50VX/Ze' Taal tength <br /> +t- _.�'�..,.. .. � 1 <br /> D' Bow 0 Type Filter MWoriat4_�iv DepIh -F tter MaReriol /� r <br /> s Distoncs tolneatesi.- Well /./Q.�.�."'_Joundvt.en `/�r Property line Lam?..........! <br /> SEEPAGE PIT [ l . Dept �Owirieter Numbs Reck Filled Yes D Nv <br /> Water Table Depllt .. . Rock Size <br /> D.stonce to nearest. WON ...""' ,Foundation - Prop. Line. ... ....... t. <br /> RE►AIR/ADDITION IPeev. Sanitarian Permits Dote 1 , <br /> Septic Tank {Spec.ty Reqvirements{ •. - - � <br /> Disposal Field [Specify Requuenantsl'__.__.:.. . <br /> t ' <br /> 1 <br /> (Drdw eeit"-and requited oddition on reverse side) <br /> 1 hereby cMify that I hew pretend IN$ vppSaOkm and that the weA will be dew is accordance with Sen Jeo%Wa <br /> Cevnty Ordineneirs, areae taws, and Rv)es anis RepvloNens of Ute Sen Jeegvin Local tfeelth District. deme owner or Now <br /> ted eyenh signetiin certifuis the following! <br /> ,'I certify that in Nie perfermence el Me week for which #hit permN is issued, 1 ahatt net employ any Person in Seth Armee <br /> t <br /> as to Mcsnre wb{act N WeAmen's CempenwNon lerwf of Ce1Hem:e." <br /> Signedlr�L�//si'v ... Owns. <br /> by Iitle <br /> f other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 1. �y J j�.J/ DATE <br /> BUILDING PERMIT ISSUED i y� F _ DATE <br /> ADDITIONAL COMMENTS ' .... .. ...._ _ <br /> Final Inspection by /y-_._ ...... <br /> JO LIN LOCAL HEALTH DISTRICT <br /> H 1 <br /> 13 2i <br /> E .'68 Rov'SM <br />