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Oct. 1. 2009 11 :48A 1 . `7 i•[ u \I >s I I. No 1432 P. 1 tcommerce. f - .n Safety and tEffi Pgs Division ' County iscon i l 2 hingj•F ie..P.O.$ox 7162 •/.2.9,1�t S t P `[Gra fon_ GGGGGOF_707-7162 Sani 40 - (L• Co.) Department of C. - • +1^ State Transaction Number Sant l:ry '§ il.;111. 1+i, •tion Qom/ Q In accordance with s.Comm.83.21(2, .. • . -i.:ton o t is orrn to the appropriate governmental Piffle / (f �'[c unit is required prior to obtaining a sanitary permit. Note; Applications forms for state-owned POWTS are Protect Address(if different than mailing address) submitted to the Det+arlment of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law.s, I5,04t1)(m),Stat. C y--.4/ 1. Application rnfotnnation-Please Print All Information ___ Property Owner's Name/ Parcel# 6 .40 x0 s 4fPo 714 r /-�/�9cV�z.r7,�1 0 -7 A7,3- 93ao�-.3 Property Owner's Mailing Address / �/ Property Location 9 7 52 Ciputr)riJ' Ali &11.11....,4,- r Govt Lot City.State Zip Code Phone Number s,/ /.. St t/ v,, Section ./er Si 44 ciry („if) 6-73„.5-e3 _(circle one) T 7 N. R E orYk i1.Type of Building(Cheek all that apply) Los N 141or2 Family Dwelling-NwnherofBedcooms ' 2 Subdivision Name Block it ❑Public/Commercial-Describe Use 0 City of ❑State Owned-Describe Use CSM Number ❑ Village of _ 7 fr/.5- 8To.onofa'X'a44 Ir-r - - III.T e of - Check only one box on line A. Complete line$if applicable) 13 New System ❑Replacement System U Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision Q Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner -fnrro tent/Component/Device: (Check all that apply) —-- `'Non-Pressurized In-Ground ❑Pressurired 1n-Ground Q At•Grade ❑Mound?24 in.of suitable soil ❑Mound r 24 in.ofsuitable soil I.-Holding Tank el-Other Dispersal Component(explain) d Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) l Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation •sa o 7 G :/3 mw.u. 9 g.. •s VI.Tank Info Capaeity in Total s of Manufacturer Gallons Gallons Units a g o`7 ,:-1 New Tanks Existing Tnnks 'a o e, i v c r aU n in an i=t., o- Septic r?'RQtllt T Tank /v,�0 .-- A:PV V / �J!Cs-c/r� % D terg Chamber Out v 6 `/ jell/ ..rT/Z ..... _, - AIL Res y onsibility Statement-I,the ondersien •.ass; ran•,•si r ity for installation of the POWTS shown on the attached plans. Plu mher's Name(Prin) P) '�� If MP/MPRS Number Business Phone Number `W 6/0/5 ' ' _,i iii ‘ D q -off ,t1&353/ _ Plumber's Address(Street,City.State,yip Code) 46ac IN& VCO A D 4'D!"tti,6 sr -Oily wt 6 3'5 a3 Vl Il,County/Department Use Only ___ Approrcd ❑ Disapproved Permit Fee Date Issued Issuing ant gnatu ❑Owner Given,Reason for Denial ... DC.Conditions of Approval/Reasons for Disapproval ---) 5 Pc i owitf /d I PA 1`0,14t 4' /11A4A9rr(---frcl/7 .044/y, II to compete play,for the srtem and manni(to the COwet,oily on Omen! s nn win Y 'aO vi c iN ; APPROVAL,DANE COUN-PY ENVIMO^`1En? �_ �P.T'-�nc,NOT-OLD(7 sELF n1D^ 2.:TRO Ch�— 2r � ' Lit P,I,.E FOR ANY DEFECTS IN PLANS OR SPECIFICA- TIONS, PLAN OMISSIONS,EXAMINATION OVER- SRD-6395(R.02/09)Valid Ihnt 02/11 SIGHT, CONSTRUCTION OR ANY DAMAGE THAT MA! RESULT IN OR AFTER INSTALLATION AND RESERVES THE RIGHT TO ORDER CHANGES OR ADDITIONS SHOULD CONDITIONS ARISE MAKING THIS NECESSARY. Sanitary ermit 2009 Template.max