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10/17/2008 08:12 FAX 6088506848 _ Septic Specialists z 001 <br /> el-0C- i157BS- - <br /> R 1,::c, r arid,�t� ! Division Catltxy <br /> commeroe.N►l.f�• i�� X . -'�iashinr P,O-Box'71162 �� <br /> ISCOPS. Madison, 5 7077162 San Lary Permit� _(to�filled in by c..) <br /> [ Health,1_,,, 010..... <br /> e State Transaction Number 9 <br /> S anit' <br /> In=cordon=with a.Corn rn.8321(2).W is,Adm.Code,submission of this form to the appropriate governmental <br /> ,td;{ rene than mailing address) <br /> prior to obtaining a watery permit. Note: Application forms for state-owned POWYS sm Project TCSS( <br /> Snit i required the <br /> Submitted to rho pepartrncnt of C.omrneroc, personal in'Ibnnation you provide may be used for secondary ��r�`E �n <br /> u• . s in accordencc with the Rivas Law,s. 1 .04 1,m State- et <br /> I. A. ,notion information-Please Print All Information Parcel <br /> property tywncr'sName► 1r� O r AI-4Z`/ 'r q S 0 . p <br /> C �— S Jroperty Location <br /> Property Owner's Mailing Address <br /> �C Govt Lot <br /> 3 a �� I Zip Code Phone Number y.. J Sectinn <br /> City,s S (��*�q <br /> � �(� P Of J 35 D 237- V3 / T rl: R, /0 r'e� <br /> ct i r'a Lot� ..._ <br /> TL Type of Building(cheek all that apply) Subdivision Nam <br /> �}ar 2 Family Dwelling-Number of Bedrooms i4— C7 <br /> Block d ter_ <br /> ❑Public/Commercial-Describe Use <br /> City of _ • <br /> CSM Number ❑Village of <br /> State Crwnod Describe Use rr`0 , eq)yyl litgown of C K <br /> Complete line B if applicable) <br /> [IL Type of Permit (Check only one boY on line A. Comp to Ertisting System(explain) <br /> 8 nr On ❑Other Modificatio0 <br /> A. System ❑Replacement 53s ❑Treatment/Holding Tank Rcpleoome 1Y <br /> List Previous Permit Number and Date issued <br /> H. 0 Permit'Renewal ❑permit Revision ❑Change of Plumber DoT it Transfer to Ncw <br /> Before Expiration <br /> IV.T 4. of POWTS Si tem/Com,onent/Device: (Check all that a, , <br /> piNon•Pressurizcd Ir1.Ground ❑Pressurized in-Ground ❑At•Gradc 0 Mound>_2• in.of able Device 0 Mound(explain)4 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component( ) , <br /> V.Dig. rerl/freattnent Poen Information: Dispersal Area Required(st) Dispersal Area Proposed(- System Elevation <br /> Design Flow(Bpd) I Des gn Soil A�pphlio4tirm Rate(gpdBO P 5e�0 1 a • 7 1 <br /> �� d l Total ,'of lvtanuibaluter <br /> VI.Tank In Capacity`r' v tC <br /> �� Gallons Units � � 3 <br /> New tanks '"'I T��' D.td cc .1 <br /> Septic or wohlimerwlk <br /> Dosing Chamber {`C"? i for in WII/idea of the POWYS shown on the attached plan& <br /> V1C.Responsibility Statement- 1,the noseralguum MIMIC rBture (bib ty MP/MFRS NNumberr 9uai'teSPhone Number <br /> T Plumb is store < F yT 7r7-0P 7 <br /> Plumber' Name(Pt'trn <br /> /e1 A . - <br /> Plu b's Address(Street,City.State,Zip Code) S-- 2 p <br /> VILI.Conn /De tumult Use On iy-- Per-t F Date Issued iaautn_ Sigaaaac ,sde <br /> .proved ❑Disapproved F <br /> [�Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for pdtapproval <br /> Aiwa,M eamplele plane re,the*ram ant rnhmr to FIN County ant?ap piper oat lase theft S M 7]l hullo%to else <br /> SBA-63911(IL 01/07)Valid then 01/09 <br />