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-. ,Nov. 9. 2009 11 : 18AD — — I . o. 1642 P. 1
<br /> - • ., Comity commerce.".1•{r :'Fi`,nl.�ni x y�`�.�p�yµ C�
<br /> i a Qc, , 201 W.:.s,� ,Ave.,P.O.Box7162 n
<br /> � M.. •n, ' 53707-7162 Seoi Co.)
<br /> `��i of,— `,',a Publi �Fiealth A:1C'
<br /> � .
<br /> t#i?;\/r u tt!� I. •i' -Traaaac ioa-Nwnhar
<br /> Sal II PP Caaun pa �3�!
<br /> In accordance with s.Comm.83.210,Wk.Adm.Codes submission*filth ibmt to the.pproprieo Seve nnrentat ( W
<br /> unit is required prior to obtaining a sanitary permit Note:Application fans tOr mte.owncd POWIS toe Project Addles,I different then,,. •.•gaddress)
<br /> submitted to the Department of Comma Petsatrat information you provide may be used for eecondary
<br /> ,,a,. in amwdancewithths• • tow s.15' .,,,Sme, Iva +h�..r y r�- Rc•,�
<br /> L Aj_pllcattionInformat ton—Please Print Alllnlbrmatton
<br /> Property Owner's Name Parcel#
<br /> (1! 11 Pl ►ti; r% 0iro6 -'o33 - 9070-Q
<br /> Property Owner's Marling Address Property location
<br /> i 01 '1 i i et_' k,e w 5 a^ s Govt.rot,
<br /> City,State . - Zip Coda phamNomber _ . W a, '3iy_.a,Section_3.:_._
<br /> _ ,I (olroleone)
<br /> 4. o ve.4
<br /> A. i W t , 3..3 `..Cu t i at) a j 0_314 T A T_ N; R ens)
<br /> II.Type of Bending(check all that apply) Lot ' -- - —
<br /> .1or2 Family Dwelling—NumberofBedroom., _ ), Subdivision Name
<br /> Block if . -__--
<br /> ❑Pub1IolCrnnme:elal--Deroribe UTe _. ❑City of,
<br /> CSM Numba - ❑Village of
<br /> ❑Sate Owned—Desaiba Use_ Town of (VI go- ' 0' :13.,1,o "
<br /> ID.Type of Permits (Check only one boa on!rite A. Complete line B if applicable)
<br /> New System ❑Replacement System 0 TreetmentaioldIng Tank Replacement Only 0 Other Modification to Existing System(napkin)
<br /> . • Previous FamitNumber and Dees Issued
<br /> ill0 Pennitkenewal ❑PerraltRevision n Change ern/mbar Q pamit7Yanecrto Now
<br /> BeforePtpiratioa - Owns
<br /> p -,. .f-BONTS, .__ CompOnent/AevieeT Check all that a' _% ---
<br /> 10 Non-Presatutred)n i o 0 At-Grade 0 Mound>,T4 hi.of suitable soil ❑Mound<24 in.of:nimble soil
<br /> S HoltliNalntr ODxrDispasal Component(espisht) A(- 6/PDlf rrr(❑PlnrtatmentDevito((Xptai)
<br /> .D ,crealfrreatmentAres Informotior
<br /> -DDeignPlow :.. Design Soil AppllcationRat'e(gpdep ■ .- - Area Required(d) Dispersal Area Proposed(ft) System Elevation
<br /> . I 0.S°.. i Aleu 9gwo f i '.to, r �iS-'
<br /> VI.Tsui(Info Natty in Total- if of Msrmfacuuar
<br /> Gallons Units
<br /> Nrw7oks ilibeng Tois ao 1 .M1 A
<br /> sq.... , -..,, Tiak ® --, WI En e-r4"s 1— X
<br /> Deeiogrba =NM 1111EMMIMEINI ter'25 r _ - _ x a .�
<br /> VII. : ■■nelbil Stetement•L the undenlpued,� 'me ' •,' for scion elite PORTS shown on the attached plans.
<br /> Plumbde Name Mink) .. MPMPRS Number Buslaese Phone Mather
<br /> t fiVttr«� lG G J� S-- IS.•ei n 5i+ r'-'
<br /> p ,•beta Addicts prat,City,States Zip Code) -
<br /> i _ ' _1. .,�-
<br /> VXYI.Co I • artmentUse + •
<br /> Date Issued
<br /> Approved 0 Diaapponcd
<br /> Permit Pee
<br /> Q ownwtylvmlteewnfarDenlal $3�.ar G 14-Z2—O? ..1 - .rt.-------------
<br /> . ( A1411/3—
<br /> IX.Conditions of Approval/Reasons for Bteapp oval /A l /G.d "i 0T 7 P4441.
<br /> — /dpi 9top(FP fMc 9c • f�# wc- c e + ;E /)2 AV ice 'r !I'C/r 1 f � ` o, ! r a�o J,. �/��
<br /> At tathto complete phas tor Mao:temood'Omit to The calmly ootr os papa nottep duo 0iiZxlt Mies torho
<br /> Chg-53ifq1 -
<br /> SRO-6396(R.02109)Valid thin 02(11
<br />
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