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10/30/2009 09:53 FAX 8088508848 Septic Specialists Cal 001
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<br /> cOMMeerl,twl.gov S ,'1 ...,:p.1121visBioonx
<br /> 4101i
<br /> _ 201 W.Li... Ave.,P.O. 7162 Ccms .ntY roa Ale-, . , o.)
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<br /> kop9 v?r, Til I 53707-1162
<br /> Department I - memo • il • Va
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<br /> State innsection •1 ,ber
<br /> ' r. i . :oifittil 0 1;414,,,- :4.1. c, • on
<br /> In accordance with s.Co , . .• - ". : '2":-.7'I-.:: *".4' , , to the appropriate governmental
<br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stale-owned POW1S era Project Address(if different than mailing address)
<br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law.3.15.040)(m1 Stitt. ' ye.//e
<br /> I. Application Information-Please Print All Information
<br /> Property Owner's Name • Parcel#
<br /> e /a Akt./14,4/ o j)//- /3 ? - .) /bel-0
<br /> Property°Yak:Y.9 Mailing Address d . Property Location
<br /> >/6 Val/rx Wid04 . 70/ . Govt.Lot
<br /> City,Stare .- Zip Code Phone Number A/4,) %, /t/eci1/4, Section Al 3
<br /> C3--c7). N; R /e/CeirPlost
<br /> IL Type of Building(cbeck all that apply) , , Lot at .
<br /> 44-1-er 2 Family Dwelling-Number of Bedrooms ' . . Subdivision Name
<br /> Block# C-Ya-liet •keLk V g.//C
<br /> D Public/Commercial-Describe Use
<br /> 0 City of
<br /> 0 State Owned-Describe
<br /> CSM Number - 0 Village of
<br /> Use -R-Town of CS 141t.
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<br /> FEL Type of Permit: (Check only one boa on line A. Complete line B if applicable)
<br /> A. cifNew Syatem 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> ' :t Number and Date Issued
<br /> B. 0 remit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New I'ist Previous Permit
<br /> Before Expiration • • Owner '
<br /> ,.. - .
<br /> IV.T A.e of POWTS S stem/Com.oncot/Devicc: Check all that•. .
<br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade Mound>24 in.of Imitable soil D Mound<24 in.of suitable soil
<br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) -
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<br /> V.Dispersal/Treatment Area Information: • Ic: "---- . Th. *\,
<br /> Desip Flow(gpd) Desie Soil Application Rate(gpdsf) Dispersal Area quired(sf) Diaper : Area Proposed(sf) , steriEJevetion 4
<br /> ■ # 04 C2 se..)) rya ItIt' --II.
<br /> VI.Tank Info Capacity in To It of Man turer
<br /> et,_ 24v.. ----"-
<br /> Gallons Gallo \ .... ..,
<br /> in Units u
<br /> New Teak. retinue Trak' . • 1 1 cia
<br /> ..0 F, A &
<br /> Septic or Holding Teak rct so 6) I t K I XleAle C:b.- .
<br /> Dosing Climber CO
<br /> _ ( e'l'6 4-01
<br /> VII.Responsibility Statement-I,tbe undersigned,assume responsibility for installation of POWTS shown on the attached plans. _
<br /> Plits Name(Print) • Plumber'.4,q) a I MP/MPRS Number I Busineas Phone Number
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<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> '73o 1. -bolt (.1... . ... r i Oe,.• 3 $-017,1
<br /> VIII.County/Department Use Only
<br /> Penit Fee tied Iss 0
<br /> / '•• -- . 1
<br /> .,,ArA n
<br /> pprovcd 0 Disapproved Date Ip .s.
<br /> 0 Ovmer Given Reason for Denial $ g DS ' -'' 16/ 3/61, .. iitt i?!:* 0A1-,''''
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<br /> Di.Conditions of Approval/Reasons for Disapproval
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<br /> Attach to complete plass far the system sad submit to the County only on paper not lets Was 8 tis s 11 Indies In sued
<br /> DB- a 1-1-13C9 %Cii)'---- NSWAIC
<br /> 1 0)1c- 535(7g5 ), i ots.-- Rev‘to ..
<br /> SRD-6398(R.02)09)Valid thru 02/11 , 4.-.....----...
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