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Oct. 27. 2009 11 : 34AM i� [ t� i tl No, 1584 P. 1 <br /> V/ Ig �^' <br /> Co1T1iT1erCe.wl Safety.., ] gs Division County <br /> j � r e.,P.O.Box 7162 / . r , <br /> lawns �iso, u�•3707-7162 �.. .i <br /> Sant :„".'R �t�,iir <br /> • i/_t(-ltt, lion State ransaction Number <br /> In accordance with s,Comm.83.21(21 ,•u. •r. • du :,tar t <br /> a su.mrsston o one o r e appropriate gavernmental <br /> u iit list required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different than mailing address)the Department of Commerce. Personal information you provide may be used for secondary <br /> • .••sea in accordance with the Pri rz_...,:.t LYtr „) ..__ <br /> Property Owner's lication Iat -P , Print Information — V Nay J,a L. 4016, + . <br /> '1 Parcel# <br /> I • A eh.t • <br /> Property Owner's . •A.:, ,' �• tf M Fro.,. • -o �� <br /> Location <br /> t <br /> 'aul-;��..,-cam - <br /> . ` Govt Lot <br /> ,. • V r•1 - 4 x Y� ►'hone Number SE . %., $E fl, Section ii <br /> :�1 • • - � .."' (circle one) <br /> II.Type of Building(check all that apply) 3 Lot# T,__(r__ N; R E or W <br /> E 1 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Sleek# 4--- <br /> ❑Public/Commercial-Describe Use _ <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of . <br /> j ., �� R Town of ,S rt_ _n <br /> i _ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)) <br /> Et New System ❑Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Permit Renewal ❑Permit Revision <br /> Before Expiration ❑Change of Plumber I ❑Permit Transtbr to New List Previous Permit Number and Date Issued <br /> ! ei <br /> IV.T 4.e of POWTS S • em/Cons•,nent/Device: Check all tint a., <br /> ❑Non-Pressurized In- round ❑Pressurized In-Ground ❑At-Grade 12 Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis.e • i - ,t. . ' •., ,formation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> Sa //r LI ry Ks—e2 q3,0 <br /> VI,Tank Info Capacity in Total #of Manutactuter <br /> Gallons Gallons Units B c a • <br /> New Tanks Existing Tanks <br /> i ci v <br /> a� a 02 l; cv <br /> Septic or Holding Tack s.to c7 H h w O <br /> Dosing Chamber Z s r MIIIIIIIIIIIMI a ■ 4' .111111111.1.1 <br /> VII.Responsibility Statement.-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 13e0 Cc c7r r t,./\ r % 0, b Q nl,_ C.z.l r .5 .3 tI c <br /> VIII.Conn roe•artds,ent use Only <br /> Permit Fee Date Issued lssuin t Signature <br /> X Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial $ v8.4 /d-2 -a g „, <br /> TX.Conditions of Approval/Reasous for Disapproval <br /> Attach to'complete plans for the system and submit m the Como,only oil piper not Iess than$r/2 x xl Indus na rise <br /> DE— ai7co a <br /> cAV- 53 Sq <br /> SBD-6398(R.02109)Valid thru 02/11 <br />