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09/10/2009 07:29 FAX 2625604795 � 0Ma11eyEom L1002/003 • � i •miner ' •ov • �,y Safe t,•F uildings Division County iti. II S EP 3 law n Ave.,P.O.Box 7162 mil► ....as 53707-7162 Sani., ••• r r • ' Co.) h • 3' g(!z1 I �' a State Transaction Number In accordance ' s.Comm.83 v , •'■. • . •✓'• sir 1 on o form to the appropriate governmental . unit is requ'.-••r or to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) submitted to ' it is.pertinent of Commerce. Personal information you provide may be used for secondary purposes in ••,ance with the Privacy Law,s.15.04(l)(m),Stars. L Applicatio I I .formation-Please Print All Information N N. y - Property+ . I' erne Parcel# Ms riei =ell Scler a otW∎ktYvl - Di 1 I-242,2. g 3_2 Property Owner" •iling Address Property Location 114""••• I I s.. VA- Govt.Lot City,State II Zip Code Phone Number N e v, N.11/4 'v,, Section 24 DDW (circle one) yoc w i 1 T -7 N; R 11 E eel • II.Type of B I•ing(check all that apply) • . 'p4 or 2 Famil I welling-Number of Bedrooms 5 I Subdivision Name Block# - 0 Pub1 ic/Co...0 I �ial-Describe Use 0 City of ❑State Owned II+ascribe Use • CSM Number ❑Village of 1141 . �lownof ()E . &live • tEL Type of P II' it: Check only one box on line A. Complete line B if applicable) A. ROW'l) ■rn 0 Replacement System 0 Tteatment/Holding Tank Replacement Only .. 0 Other Modification to Existing System(explain) 1 I I List Previous Permit Number and Date Issued B. 0 Permit i'.. wal 0 Permit Revision 0 Change of Plumber ll ❑Permit Transfer to New Before• ration Owner IV.Type of P System/Component/Device: (Check all that apply) • Non-Press '•••In-Ground ❑Pressurized In-Ground 0 At-Grade . ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil 0 Holding Tank! 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) • V.Dispersa to atment Area Information: Design Flow •v l Design oil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation ..75c) 1 J 1 -)S I I,Q. '7 I 14.-7, grips 9 a 3' VI.Tank Info/ Capacity in Total #of Manufacturer Gallons Gallons Units Al v New Tanks Existing Tanks t 1 /i P . a. CA co V) 'w'O . Septic oFuolding'lii k vasc, 1u O 1 loeoat K • Doting Chamber b •m VII.Responsi ity Statement-I,the Undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. 'Plumber's Names W rint Plumber's Signature 3efP/MPRS Number Business Phrnme Number fb,dl .l M2t1�l�..t12. I -Lo , w. (a:mi u5 r s33bao3 Plumber's A.. (Street,City,State,Zip Code) . ' • 3 •P . ..NR.162-1--j 1/1 53 SI1 VIII.County 1 partment Use Only • pproved I Disapproved PtvrnirFea Date llss q Iss ; :op I I t Owner Given Reason for Denial $314 S.bb •1 310 ' `''•l•-"‘/, -.� '� IX.Condition !f Approval/Reasons for Disapproval Rt (iRANTINU THIS APPROVAL DANE CR%' !'Y ENVIRO' .tt-1 Ts.• L"-P'-y!)N .1 1'1^7'IOW ITSELF LI!'z'.F e'OF!ANY DEFECTS IN PLANS OR SPF()Flr A• • Attach to waspish)plans for the tystsa,and submit to the County only on paper nofWiS fa�IPPYttinierMSNONS,EXAMINATION OVER 5t'33HT, CONSTRUCTION OR ANY DAMAGE THAT M4 p^'gAK°��'�t, • RESULT IN OR AFTER INSTALLATION AND RESERVE l.�' 5 31 THE RIGHT TO ORDER CHANGES OR ADDMONS • SBD-6398(R.t• 09)Valid thus 02111 SHOULD CONDITIONS ARISE MAKING THIS NECESSARY.