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May. 2009 9: 21AM No. 0560 P. 1 <br /> ' t - °r <br /> ( _( tl Cdr. �}1 <br /> commerce.W1 g "- SiTelyantlr it �ngs Division County• '°;4 201 W.Wdshinl n1 vc„P.O.Box 1167. 1 �Q <br /> • t S C O! 1 S I 1 MAY 13 21651is°r• I; 3707••71 b2 • Sanitary Permit Number(to be filled in by Co.) <br /> Department of Con' o e '/` 0/9 <br /> 7111 ii rt.p { A r l 0I M,. State Transaction Number ---..... <br /> In accordance with s.Comm.83.2I(2,Win. q� pjeirs4• op.4tigiF/l'omi to tije appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Nile:.APPheatiotr tVn„o f„ state•Owntd POWTS ate Project Address indifferent Mon 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.I 5.04(I)(m),Slats. _— ,U (�(��� �1�� <br /> I. Ap11licatlon 1 nfOrmatlon,Please Print All Information G c9 'c <br /> Property Owner's Name 'r•ran Parcel R✓pu,J” Dz2. -b zzl- C3 <br /> Property Owner's Mailing Addres• I,r 73 j 3 (y ogi Property Location <br /> (2 _j �.�....._« .:..'._OCA r'•�f`trd•� br. Govt.Lot <br /> t:it f State i 2i Code 5391( Phone Number N( 'A, 1\16.) '/, Section rpm\A+ C code one) <br /> 0 V1 r lYN-k 5'35 9 0 11 <br /> II:Type of B tiding(cheek all that apply) Lot N <br /> l Subdivision Name <br /> 1 of 2 Family Dwelling-Number of Bedrooms G (9d <br /> Block if Irkt..S! 4io I 1 <br /> n Public/Commercial-Describe Use -_ �' ❑City of <br /> ❑State Owned-•Describe Use CSM Nunl>cr.� ❑Village of___ - <br /> _.... _ A Town of..._. If 144- <br /> ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System 0 Treatment/Holding'lank Replacement Only U Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal © Permit Revision U Change of Plumber ❑Permit Transfer to New 4 List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> 1 .Type of POWTS System/Component/Device:SCheck all that apply) _— �_� <br /> Non-Pressurized In-Ground ❑Pressurized In•Gtound 0 At-Grade ❑Mound>24 in.of suitable soil U Mound<24 in.of suitable soil <br /> n Holding Tank E Other Dispersal Component(explain) _„• ❑Pretreatment Device(explain) -,- . ..., <br /> V.Ulspersalffreatment Area Information; <br /> 'fiesign Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sl) System Elevation <br /> a 6 Lf I Soo 1 5 Oc, 9"7.2., <br /> VI.Tank Info Capacity in total II of Manufacturer <br /> Gallon: __ Gallons Units y �v v v <br /> New Tanks Existing Tanks” a d is <br /> _, <br /> Septic or Holding'fank L'�,9D —_ ...... -11P° i 1 / , _ -.-•- <br /> Dosing C'hamber So° ,..,. i.:4) /` r / •-�•• <br /> V i I.Responsibility Statement- I,the undersigned,assume re onslhility for installation of the POWfS wit on the attached plans. <br /> Plumber's Name(Print)1 1 Plumber' i 0 PRS Number Business Phone Number <br /> i(:cc—, 1'4154' .y `Z 2-`'412 /255• X23"{El/ <br /> Plum 's Address(Street,City,SZip Code So-ic QC, (..;juli.,A),/, VI- 5-13.7z,c <br /> VIII.County/Department Use Only • <br /> ` Approved ❑Disapproved Permit Fee Dale Issued Issuing a Signature <br /> n Owner(liven Reason for Denial r_3(o'rl •� ,.r°~`,/ X/ _-__„ „—• <br /> iX.Conditions of Approval/Reasons for Disapproval <br /> • <br /> �} 3.1,1.9, ) _.Attach to complete plans for the system and sabmtt to the County only on paper net less than a 1R a I t ruches in site <br /> ehK r • r31.0 .DU WJ C.USTM 4-iOME 170q DwrieSinieul <br /> S13L).6398(R.02/09)Valid dint 02111 <br /> S c t•• �- <br /> P. ,.� 0 <br />