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• Aug. 12. 2009 9:34AN - No. 1110 P. 1/2 <br /> , M IEC .EadE n . <br /> commerce.w _y� Safety an ngs Division County <br /> 201 W.Washin..f 1 e.,P.O.Box 7162 p{A,rt IL, <br /> ei !S/'t/'�M r A G 1 2 isor :3707 7162 Sanitary PermitNumber(to be filled inbyCo.) <br /> Department of Corn - ' _____, <br /> State Transaction Number <br /> Sanit; • •_ , i- lea .on <br /> In accordance with s.Comm.8121(2 :•t, '•.tl.111,3 .;.io.Jr.,-;..hi••• , appropriate governmental <br /> unit is required prior to obtaining a sanitary pcnnit. Note: Application forms for state-owned POWTS are Project Address(if dilferani 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,s.15.04(1(m).Slats. �- A.-;\....1 p a ,f`Gt <br /> I. Application Information-Please Print All Information vw h ow% <br /> Property Owner's Name Parcel# <br /> P\ , O ( C Ire `∎, 051,- 676% -30 -SS'a-. 0 <br /> •Property Owners Mailing Address f Property Location . <br /> )..0 ? JJ0 ``h 1...�OJA SA' UV.0 ((� Govt.Lot <br /> City,State • Zip Coda Phone Number 51x1 '., $(n/ y., Section 1 0 <br /> C\.' ` \y ( a e) <br /> C.a O I .��t circ on <br /> T N; R ( (or W <br /> IL Type of Mining(check all that a y) Lot If <br /> -I or 2 Family Dwelling-Number of r3..roe 14 1 t)-` Subdivision Name <br /> • Block# ■.. kJ Ws.Ire, (OI^to <br /> Q Public/Commercial-Describe Use <br /> Q City of• <br /> ❑State Owned-Describe Use CSM Number El Village of <br /> aTown of S c t J %,.-e.,1 at <br /> 111.Type of Permit: (Check only one box on line A. Complete line 13 if applicable) - <br /> A. , New System ❑Replacement System ❑Treatment/Flolding Tank Replacement Only Q Other Modification to Existing System(explain) <br /> iL ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Trnnstbr to New <br /> Gist Previous Permit Number and Date Issued <br /> . Before Expiration [Owner <br /> • <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) - . , <br /> ,ja Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade ❑Mound>24 is of suitable soil Q Mound a 24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) • 0 Pretreatment Device(explain) <br /> V,Dispersal/l'reatmentArea Information: <br /> Design Plow(gpd) Design Soil Application Rete(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 3 .I. <br /> k7(•)b s labs? I aob qi.‘ , °N4,A t. .i <br /> VT,Tank Info Capacity in Total li of Manufacturer <br /> Gallons Gallons hulls a 8'$ p0 <br /> NewTm(cs Existing Tanks ;d <br /> a, 6 co w l5 w <br /> 'Septic or Holding Tank '1100 labs] 1 AA.-woke. V <br /> bosingChsmlxr C 00 — 1 60 l Il' v <br /> VII.Responsibility Statement-r,the undetsl8ned,Milne responsibility for Ins/idle lio of the POWTS shown on the attached plans. <br /> 'Plumber's Name(Prii`nt) Plumber's Signature MP/hiPRS Number ' Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) I <br /> 1 c-t- 4-�.�,. k. t✓t,.rk 1C e e L.,t 5 <br /> AY <br /> VIII.County/Departn ent Use Only �+�r <br /> Approved ❑Disapproved . PC tree Dale -sued, Issuing � � <br /> Approved <br /> 0 Owner Given Reason for Denial / 46 fA r ���- _ <br /> IX.Conditions ofApprovalReasons for Disapproval �� . <br /> Attach to complete plans for the tytteu end submit to the County only on paper not less man a 1)2 s 11 inches In size <br /> IA—. )-7%a 8 <br /> OAK- • Si (aO 7 - <br /> S13D-6398(R.02/09)Valid thru 02111 <br />