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' Aug. 27. 2009 11 :03AN A E C E [I V IE No. 1223 F. 1 <br /> commefce.W Safety an i d ngs Division County <br /> At 2251 l�q rshinh t 'e.,P.O.Box 7I62 []Avg <br /> tiscons . '�5��'dison !3707-7162 Sa tit le it .-) <br /> Department of Comalera, `rte+ <br /> Sanity T raj, Lion State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wts.Adin.Code,submission of this form to the appropriate governmental • <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for sta[rownCd YOW'I'S aro 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 Privacy Law,a.15.04(1 xm) Sots. <br /> I. Application Information-Please Print All Information W J 0 1 )1,..16ty <br /> Property Owner's Name Parcel N <br /> C;-en 4- kv-A14 A10 14 p,(( 011 1-VI --`-f 3&/-65 . <br /> Property Owner's Mailing Address Property Location <br /> On 2 t'1 Govt.Lot <br /> City,Suite � Zip Code Phone Number St�1 K NE v., Suction 111 <br /> ,�ivx T►�•µii e tn1t • I tr N (circle one) <br /> T <br /> ( 49 N., R i f E ea 3V <br /> II.Type of Building(cheek all that apply) Lot# <br /> IPI ur2 Family bevelling-Number of Bedrooms_4 11 Subdivision Name rr�� <br /> Block ii WI'Noy P-vei aim-K$ <br /> ❑Public/Conrnrercial-Describe Use <br /> O City of _ <br /> CSM Humber ❑Viltageof <br /> ❑State Owned-Describe Usc <br /> %Town of BI-; I <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. "New system ❑Re p lacement S y stem 0 Treatment/Holding Tank Replacement Only 0 Modification to Ex stin g S y s[em(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to New• <br /> List Previous Permit Number and Date Issued <br /> Defore Etpirat ion Owner <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) <br /> pNon.Pressurized In-Ground ❑Pressurized In-Ground ❑AI-Grade ❑Mound 24 in.of suilable soil ❑Mound<24 in.of suitable soil, <br /> ❑Holding Tank ❑Other Dispersnl Component(explain) , 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> 15esign Plow(gpd) ' Design Soil Application Rate(gpdsl) Dispersal Area Required(sf) Dispersal Arca Proposed(so System Elevation <br /> ("CO 4 Irk J. 1512 1eit0 j A ,sit '.ca/ <br /> VI.Tank Info Capacity in Total #of . Manufacturer <br /> - Gallons Gallons Units ? C v <br /> • <br /> blew-ranks Existing Tanks 4 2 k E a�u <br /> • W U Yn rA W t7 PK <br /> 02 tkloldiagTtnl l2 I `' l Midd. x <br /> Dosing Chamber — 1Qt;o i „ k <br /> •VII.Responsibility Statement-I,the undersigned,Assume responstbtltty fir lastnllation dike POWTS shown on the attached plmrs. ' <br /> 'Plumber's Name(Print) Plumber's Signature WIMP RS Number Business Phone Number <br /> fthe'll ,W. +1 4012. c— -- U.1 Ali 22016S SSI-Bi03 <br /> Plumber's Address(Street,City,State,Zip Code) M <br /> 6e l,. C74-4- K V•U'u r 1 Yell 5 ,11-7 11111 I - <br /> VTII.Countylpepartment Use Only - _- , � <br /> Approved ❑Disapproved r Permit Fee Delc Issued Issuing cut SignAlwe . <br /> Q Owner Given Reason for Denial $30 t t /14 ,tom <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1. <br /> 03-E)13 .. all 35ttath to complete plain for lite system and submit to the County only on paper nol less than 8 irax 11 inches in size <br /> Ir■ —5 lg1/1 <br /> SBD•6398(R.02/09)Valid that 02/11 <br />