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9...)(1511 t) • <br /> e <br /> y''i: ‹} t Safety and Buildings Division 114.icV ryvt:T <br /> II _rf_ .fi201 W.1Naskt ngiOri Ave.P.O.Box r 1432 Sa-Stacy•Permit 1a:nber(to be Filled in by Co.) <br /> � ?"1• t. i rt. �_., S'7 r73-7 <br /> �:s <br /> Sarut r Permit Application Stare f/r�a,s^Tar Number <br /> i n a CI-VabrrCc with SPS 3.3.21(2),!Ys Adm.Code.stibmissiert of this fon,ro the eiy-fttazaie gortzrs�-i 1 to t C_ ,,.6)1 i?C V I r-) <br /> is requird prior to obtaining a _rt;tory i cmttk Mate:Application fauns for 3+�c7-oKT , POW XS V5 t tMO: to Project Address(indifferent than retailing address) <br /> the Dcperoment orta <br /> Sawn-and Profession..)Servics. 1 rn,.J aubaaanar yeas prove scut- used tor s <br /> purposes in accordance with the Prirecy Lew.£1 Ds(3)0,m).Stat. <br /> I. ;.pplicstion i nrorrotion—Please Print All Information .5.3 rel G <br /> Properner•s)carte_ <br /> eper} <br /> ck k L o eitoci if <br /> r- 0-z-3718-17-y oy-azo-crxtao <br /> ~Praperr,-Owner's Mailir-Address P,op.s Lir i s.tie^ <br /> (2221 Coac) i Cost.Lot <br /> City. <br /> sState Jamf�//' k.1%) Zia Code }� !Phone Number Q� ' 5 <br /> tki <br /> it.Type of Building(check a 11 sleet apply) Lot= T 37 N. R E t r R <br /> Yi I or 1 Ferny Dwelling-Nvrtb.r.. demes / s ivisio:Nance <br /> . 1 Block= - <br /> ❑Publsc'brnrnereiet_Describe use <br /> ©City of <br /> ©State Owned-Describe We ! CSM I.Z°ter 0 Vr3IZgr Of <br /> - 7ivi Lk- <br /> �Tmvn a; <br /> Lill.Type of Permit: (Checit only nue boa aro IUOA. Coasple:eline Bifa parable) • <br /> A' q sktt System Li R S��efn <br /> e ye: 0 Tt taeaal etylingTotre Lioincenneret Mly # 0 Otter Modifimtian to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Ae% ion i Q omnee aplcmb_r L re-mit Ttata ..to New Lan Previous Permit Number and pate Issued <br /> Berne Expiration 1 r:a1 Oer J <br /> 111 <br /> L Ile. Type of POWTS 53sternrCocrportentrneviirc (Cheek sfl tsar apple) <br /> 0 Non-Pressurized In-C-ound 0 Pews. In-Ground 0 At-Gado 0 Mound?24 in.o!sui:able Q Mound<24 in of suitable soil <br /> 4 Holding Tait. 0 Other Dispersal Campoctear(exptsn„ • 0 Prs+seeGrsert Devi=(ter i.} <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(Wi) ( Design Soli,fp-.,licaio r gp&f) Diol Area Ic ed(Sft Di Del Arta Proposed isf) System Devotiony60 € — r <br /> F�-I. Tank Info Capati 'ei i Trs l I S of Manufacturer <br /> T <br /> ve:ilarrs ( iti7or6 L':.:ts sa ^ c•? _ ' <br /> S:s+•T�Xs cris:irk Tema c"s t' ti Y _ <br /> I ? 3 a1 <br /> --J m n v_ —U <br /> S titer lfoldiet Tari t "7� E ?Q70 T r GA'/' w - <br /> Y. <br /> Doeirtc Cas.+rber I ! 1 l . i i <br /> \'I I.Responsibility Sratcenen t-1,the rind ed. reesponsihrecsfor instaltr!ion of Oar POWTS shown no ehr nttaclrrd plans_ - <br /> ! acts s Name(Print) Plranber'sSgoe. '-- <br /> MP/MPRSNumber Busses Phone Number <br /> 1 ,�lv l�r e.- i , e6-199-f ,7/5 866 70 - <br /> Plumber's Address(Saar:-City_Sorra ZipC y <br /> i. <br /> • <br /> ^!'iii.CountvfDcpartmcnt Use Only - <br /> tittlpp Approved 0 Di rcve; i Pc.gr Fee Dsee tarred ( tsstr l igtzt <br /> I `375 I I,Z t. ., rpt 5 i <br /> # 0 Ovynct Givers Anson Far{J�al - _- <br /> IN. Conditions of Approval/ft canons for Foliripproval <br /> 1 t5orl R 4 s Ar .Burdett Cou tf- i ndictxte. S53 G : etA,J T4O c 5a►001 • <br /> I <br /> t 1 <br /> .yrocb to co:rsattte aloes for the caner wear to- o• on --t areal in she <br /> SBrD-539S(n• i I/1('r <br />