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Sitcl, and Baddin¢i Dlu,iil CGouit_ <br /> ` W '111 1C. \l a,hinggtn A\ e. P 0 BoN 71 n' 3arn ie <br /> iseonsinMJdI,tlll 1 'I Cis janitar; PJrl nil Nu n ihcr II.,be tilled in b: <br /> Department Of Commerce Ihit's I2hn-'1'1 11908Q a8? 3 <br /> Sanitary- Permit Application Sta1e Nail ID N"....her <br /> In aa"nJ with COmin it 11.1l,s Adin Code.personal m6mmnon•.tau pnn idc <br /> may be u,ed tar secondary purpose,Pnsacy Law,,I i oat I(lilt <br /> Pngrct AJJre„til different dun nuJing a.IJre„t <br /> I. :lppliutiun Information-Please Print All Information <br /> Property Owners.Name <br /> J ��DParcel a Lot x Block a pc <br /> At PAlwls/ern— S/�i1 a� y 03p1 sYdS oat .sap <br /> Pripcny Owners Madmg AJJresi <br /> Property Loc anon <br /> 57/7 Red Poll Ave S. ,-ej�µy� <br /> City.State Zi Coda '• '-"" . Section otS` <br /> P Phone Number <br /> New Prat we /W A/ s6071 9s,�-�sg-30� cle one) <br /> If.Type of Building(check all that apply-) T y/ N, R i7 ordv <br /> ly 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdi,i;um Name C S%I Number <br /> ❑ Public Commercial-Describt Use <br /> ❑ <br /> Stile Owned -Describe Use ❑City_❑bllluge�'ownshtp of Sar.zSb W. <br /> 111.Type of Permit (Check only one box on line:%. Complete line B if applicablel <br /> ffExpiration <br /> ❑ Replacement System ❑ Treatment Holding Tank Replacement Only ❑ Other hlodi icaoon m Existing System <br /> B. ❑ Pennit Ratstun ❑Change of List Previous Permit Number and Date Issued <br /> ❑Ptnnu Tnn;ier to New <br /> Plumbtr Owner <br /> If. tem: Check all that ARPINl <br /> R Nun-Pressurized In-Ground ❑ Mound>?q inof suitable sod ❑ Mound<'a in.of,unable soil ❑ At-Grade ❑ Single Pass Sand Filter U <br /> Constructed Kalind ❑ Pressurized In-Ground ❑ Holding Tank ❑Pcat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating S,mhenc Media Filter ❑Leaching Chamber ❑Drip Line ❑Gn,cl-las Pipe ❑Other(expliml <br /> crsaliTreatment Area Information: <br /> Desygn flow IgpJt Design Sud Application Ratti gpdsl) Dispersal aro Required tat) Diipersal ArMdSystem Lle,auon <br /> J_ 900 700sq,3f 1.Tank Info Capacity to Total Number Manufacturer ite Steel FiberGallons Gallons of UnitsPlasticructed GlassNe. Existing <br /> Tanks Tanks <br /> Sepoc or holding rank /oeo /6002Atrubin Truimtm CmrDuring Chamhcr <br /> %If.Responsibility Statement- 1,the undersignedassume responsihility for installation of the PONTached plans.Plumber's Name IPrinty Plb ' $ amreMIs MPRS Numbersiness Phone Number i 5=866— 4IC_7 <br /> Plumbers Address(Street,City,State,Zip Codel <br /> 7760 /�w <br /> 3S- Ovea(ts/r,. G✓s 5-��j3 <br /> 7aZQureh3rge <br /> nt Use Onlyrmcd Sanitary Permit Fen Date Issued Issu•ng. ignalure amps) <br /> Surcharge Feel r Given Reason for Denial r �, �I'oval)Reasons for Disapproval <br /> Irl•^ •, �r <br /> t i i <br /> ar 2 <br /> S It+U 1 L✓' <br /> SURNS77 C(.,, <br /> Alsnch complete plans lift the Count,only I for the system on paper not less rhoffifillify,14 1 JIMS in sire <br /> SBD-6398 (R. 0103) <br />