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Aug. 24. 2009 9: 30AM , _ g 1 L !I W u� t No. 1193 P. 1 <br /> r� cammerce.wl._�IA Safety sad IN.g.,siniDiv.,ssiooxn County it <br /> UG 01,�Vtr'shin: 7162C't �C i sco n s 1 I , 707-7162 Simi Co,) <br /> • Department or Comm: 2N0r3fiedar, <br /> Sanit. y P P'[ /f 111 f! lion State Transaction Number <br /> 1 11 tl 11�� S,.an t h <br /> In accordance with s.Comm.83.21(2), . r •. in., L.imtssion o' is 'orm o e appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different 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 Privac Law,s.15.04(1)(m),Stats. <br /> I. Application Information-PleasePrintAllInformation >Q iti[..1 ,r4...C. /O <br /> Property Owner's Name Parcel# <br /> ,.-5 1, £t/,'-4. bC/4 /175-:)- ( fo x D jd,S'- 30 - QD('s-z) <br /> Propert Owner's Mailing Address Property Location <br /> 4P 4F r° -. ti / . Govt.Lot <br /> City,S at Zip Code Phone Number '' SS, 3fi <br /> ��4 /P !!�/., {f!v /., Section t_/ <br /> - ii 4)� (, G+) circl ne) <br /> II.Pipe of Building(check all that apply) Lot 4 I T N; R Vtl <br /> or 2 Family Dwelling-Number of fledroom ! J Subdivision Name <br /> Block{I <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use I `� `�, �/ �� �� ��� <br /> 1 P b C /1 own of /"/ Z 7 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)(J <br /> A if ew System L y ❑ Replacement System 0 TreatmenE/llolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> tV.'Iype of POWTS System/Component/Device: (Check all that apply) <br /> T[i)- Ion-Pressurized In-Ground ❑Pressurized In-Ground El At-Grade ❑ Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Othcr Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V,Dispersal/Treatment Area Information: • <br /> Design Flow(gpd) Design Soil Application Rale(gpdsf) Dispersal Area Rc uircd(s Dispersal Area Proposed(sf) 1 System Elevation <br /> 7,5____ K db� � / 7 r/ 1� �'�o <br /> VI,Tank Info Capacity in Total if of Manufacturer <br /> Gallons Gallons Units D e o ,u <br /> New Tanks Existing Tanks v 2 1] n <br /> / w U rn co w t7 P. <br /> Sept, o.Holding Tank /� , ! 6, / {-----��=L e c <br /> Dosing Chamber lJ rX <br /> VII.Responsibility Statement-I,the undersigned,assume responslbility for installation I be POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber'•.uj• MP/MPRS Number Business Phone Number <br /> k R er-03 .l 7A -' c)d 7efa .c96'.- e V9- d-'71 1 <br /> • ,. .er's Address(Street,City,State.Zip Code) MOW' <br /> 13(o L ---DOIr r L r \ (3, bkAle_ Wr x- s 3 -off 0( <br /> 4vod unty'/Departmenl Use Only <br /> — <br /> Permit Pee Data ssued Issuin -ir � <br /> El Disapproved �J <br /> $� 1� •-- s _ — _.... <br /> ❑ Owner Given Reason for Denial j � �_ _�.._ :J -- <br /> 1X, Conditions of Approval/Reasons for Disapproval .viiiiv <br /> • <br /> Attach to complete plans for the system and submit in the County only on paper not less than 8 llL x 11 Inches to size <br /> 0$ - elf 2' X77L.f B <br /> hl-- 51837 <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />