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U { C f c* T S i i 0 _•7til <br /> e lnerce. Division C <br /> ta <br /> clintY <br /> �� . SEP 2 420 w , , Ave:.,P.O.Box 7162 0 c <br /> I sec n - M ,, ., , 53707-7162 Saniary Pant Number(n be filled in by Co.) <br /> • a l Health 51 e 1 C0 c <br /> ry 1 red 1 Stair Transaction Numbs <br /> ♦ �'_;Lel t "��a"� jjp,C �r�/�]� /per/J� <br /> Salli.,, Ill ' t p vi ' on <br /> �}, �Jr ,l 1/'7 <br /> In accordance with s. Comm. 8321(2), Wit. Adm. Code, aeon 11f this,form so the appropriate PACE /"l1/ <br /> governmental unit is required prior to obtaining a sanitary permit. Note:-APPS farms for stale-ovrnea Project Address(if dim than miulmg address) <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stan. I i t„,y 3 t: <br /> L Application Information-Please Print All Information Pared- <br /> Property Owner's Name <br /> I14,...ro l c.I4 P S G ►^ i?Al. 05c7 o n 3 - 71 c=00 -� <br /> Property Owner's Mailing ddress Property <br /> 15-3 -1 I.4iA--'y T C Govt.Lot <br /> (Sty,State Zip Code <br /> Phone Number /qt.= 34, 5i.� lf.Section MI-. har�b 5-3 3-2.4 (-cg) 437 ' <br /> i/d- (circle( �Fone) <br /> II.Type of i dh ing(check all that apply) Lot I <br /> Subdivision Name <br /> H1 1 or 2 Family Dwelling-Number of Bedrooms <br /> 3 <br /> Block S <br /> 0 Public/Commercial-Describe Use 0 City of <br /> CSM Number 0 Vrllage of <br /> o Sate Owned-Describe Use [Town of 9 T e ,v, f c s 4z <br /> • <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A- RI New System 0 Replacement System ❑TreatmmdHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 arm ee of 0 Permit-minder to New <br /> list Previous Permit Number and Dose lamed <br /> Before Eviradmn Phnnber Owner <br /> 1 <br /> IV.Type of POWIB System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized ln.Groum 0 Pressurized In-Ground 0 At-Grade ®Manna > 24 s.of suitable soil 0 Mond <24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dlspt nallTreahnent Area Information: Area Proposed(s0 System Elevation plow(gpd) Design Sol Application Rate(gpds0 Dspasal Area Required(at) Dispersal <br /> 2-1.51, 0 . u 4 5-0 q SS. /0 /. Vic:" <br /> VI.Tank Info in I <br /> Gallons Units v s - .g3 ' <br /> New Tads Existing Tads U in CA u.c7 w <br /> Septic it *Tank �.OC ` L f.e fi` X <br /> /Cc'C' I t<'Cc= 1 <br /> Dosing Chamber <br /> 1.1,0 v tone I cl v e•.5 t h <br /> VII.RespOnsibility Statement- I,the wed,assume responsibility for installation of the POWIS shown on the attached plans. <br /> Plumber's Name(Pre t) 's tore ° MP/MPRS Number Business Phone Number <br /> �`, p �"' `r �(,J°"°� ° lt;.° '`I (0 64",$),2:v�S- Gil ice <br /> S�czr 14. tor- <br /> Plumber's Address(Sued,City,State,Zip Code) <br /> _, ' 3 3s'o7 <br /> VIII.County/Department tm Only Permit Fee Daiz Issued jffire <br /> Approved ❑ Disapproved <br /> ❑Owner Given Reason for Denial S e 9 b i<0-2-0((,? <br /> c 2r4 1-0- <br /> I%.Conditions of ApprorallRessms for Disapproval <br /> -r-?5-c g9 wt f j IMPA-(i '9 (44.1/ <br /> f c.)?.lec -1,<- Pte, A r tint_.. <br /> Attach to complete pros AK the system and submit to the County only on paper not Mss than 8 112 au imam is size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />