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FROM :veronaseptic FAX NO. :8457466 Mar. 09 2009 02:22PM P2 <br /> ta crttrticQ. 4; Division Coaaty <br /> `.k1 AUG 2 12'-Ir:W�. • .•��,� A -,P_O-Bm7162 POJG <br /> SCa f In 517°7 7162 Senn a' Permit Number(to be filled is by Co.) <br /> Department nt d Cat tnerce--- - f 5/8 / <br /> S; 1 r�!L*11 7 II State Tiansaction nNumberrAve_we vla+ <br /> y In accardaaee with s,Comm_83-21(2),Win.Mn.Co de;submindos ortbis form to Ilse appropriate 157'8 I'd 1f A,/!( <br /> unit is required price to obtaining a sanitary permit. Nair Applcion farms for sore-owned POWTS me Project Address(if diifferent thin mailing address) - <br /> . submitted to the Department of Priiv.C�w*.1>� information you provide may.be used for secondary iit 'S3 3Gf-tdK 1 or vaA. <br /> Purposes in accordance with the X. APPikagioa information-Please Print All Infor>ittion <br /> Property Owaee's Name - .— <br /> • <br /> -- Parcel!€ <br /> 5 G0rr- At-FLAA.A-,-J 17607 2-23 ezi d 9 <br /> Property Owners Mailing Address - Property Location <br /> (:.2 3 S po w e r.)-r-S, A .. <br /> t:uy,State Zip Code Mow Number b" ps 51.%) yy s.aioa mil..7 <br /> r &.o,-5 l 535'7 o8)X41 - 0 3 <br /> IL Type ofBuil (deck all that apply) - T N: R_ E <br /> rtes -hambet aft `.,_, Sobdivieion Name <br /> Block a <br /> 0 Publd e, <br /> Comarciel-Describe use . -- ❑city of . . . • <br /> ' <br /> • 0 state Owned-Describe Use CSM Nom_ ❑Village of <br /> Itii Town of - P auto A- .. <br /> IIL Type of Permit (Check only one box on Dine A. Cotmplete.6me B if applicable) <br /> A. ew Sytum ❑ Replacement System ❑Trntmeat/soldmg Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Pmt xevistaa 0 ot?lensbar 0 remit Transf r to New sit Previous Prat Mandan-and Date Issued <br /> Before£c an Ow= <br /> W. a• ofPOWTS „ .. , 1 . Meek all that .ti, <br /> 0 Ncn-Pe ed In-Ground Q Pressurized In-Ground made 0 Mound>24 in.of suitable soil ❑Ma®d<24 it of suitable sail <br /> ❑Ratan Teak ❑Other Dispersal Component(explain) 0 Prea eatmma Device(oaplain) <br /> - <br /> .. <br /> V. i- , -, .,, •t Area I I> : <br /> Design Flow( Design Sod Appliestion E daf) Diepetsal Am Reginald(ill) Digiasul Arm PPapoeed(sf) Sytasts Emden <br /> 7c7 b-. f 2 S. / s-oe. . /ze. e)• <br /> VL Tank Info Capacity in Tonal #of Mmo iletur r <br /> Crakes Gallons Units .o 'ar- till a <br /> U iii O.$ <br /> Sepia r Teak /4 era r MI PAL Wt Pr•R P.`t' x _11111111111111 <br /> VP-Responelaitty Statement-I,t h e mire s.um= -- • _ , . -••. , . .• •• ' a, .. -.. .M <br /> Plumber's Name(Print) Plumber's Sites '1pP/MPRRS Number Easiness Phone Mamba <br /> • <br /> TIvN9TH`r J-eLL - - 227 S2S 00 BEES--'7'/64. , <br /> Phtmba's Address(street,Ca;.State,zip Code) % <br /> • V t`(2-0 r-1 A 5a P•r'C * EAc C A ViVrtio& Sot C.dwt Ai ERCE ()LLI�Y) Vat)/1 , CA-J X 3 5 93 <br /> v1DI coin zil.. -. use e , • _ <br /> gal Q Ihsapproved Permit Fee 72?"-"j ` 1�L9s<t.d Iseuutg _-_//��'' - `���""^' <br /> p 22 -0 e I iAl>/ <br /> 0 Omer Given Reason for Denial $ U~ / tamiAr#4. ~ Y <br /> IX.Conditions of Approval/Reasons for Disapproval IN GRAN ;NG TI-i1S APPROVAL,DANE COUNTY <br /> --4 po�(� 4,4/v/,f 2 -p 6,47-4/.(e ENVIRONMENTAL HEALTH DOES NOT HOLD ITSEL <br /> LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFIC - <br /> _____ Trio vort . 5(77 0 Ef'(-tf ,Y Gores. Foe A44 fi S ?�s6MI F ON OVER- <br /> Sin , t ,f*:��s � <br />