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Sa> y Ptt *PP&SGM 201 W.w A <br /> In accord wilh Comm 9321,wI.Adaa Cade PO Box <br /> 3 see Mvax side for instmcdoos for Compkdog this app6eation ice.Wt 53707- <br /> / . A Pa=W iatomn6oa pw pmvide nm be wmd for scceedmy poem Oubgait=mpkfAd form to cOGUtY ifft <br /> Department of commerce D%Vaq Law,s 15.01(lxm)) state <br /> Attach (to the touaaY caPD'aa1Y)f a the systrm,on not kss tbta 9-112 x t 1 awbes in sor- <br /> SYae ro Sucre t7e 1 D.Mewl�ar M <br /> County <br /> L Iw[oratwtiow-Pivsse Ptgt a9 Lforaaatlow I.ocatioi: <br /> I"alY taeawa <br /> Jr- <br /> zip Naas or <br /> i.S J--P7Z1 ol3 CR <br /> � <br /> r"13 <br /> at (da&ttwe) OWIF <br /> 1 or2Family Dwdft-No.of Bcbooaas: Z 11Twmof <br /> Pwblidrbo S=w(dt�c vwestate ownod 2 — MEMO Nowl <br /> ZE' ftLts <br /> L L. <br /> T . ZP Aft AMP w 3 <br /> Type of PonaiC (ebaek otaly awe boat ow live A (]Kdc boat an line B if ) S aa- <br /> A) 1 2 3. T Replaoeoent Eldon SYSM <br /> Slrstem Systeoo IMM:issuca <br /> ❑A Snitary Pamir was t!!!!d <br /> rv.Type of POWT Systean:(Cbu :aU that aPPIY) ❑r�orma ❑scrod Ftlta ❑Ceasin cted wetland <br /> 0 Pvcss f nd In d lo-gaoamd 0 Hobft Tai• 0�Pass. a Drip Lias <br /> 0 PtesArdt Lt-�oubd ❑Aerobic Ttalmal Unk ❑Recaatlams ❑Owlet: <br /> o At-made -V. Ars Lformstios: Ekvaaaa 7. <br /> Area Arca 4.Sollftlkafim 6. <br /> woe(�Yk9•R) �meA) Ekwation <br /> AoPesed <br /> VII.Tarek CaP Y is Total f of NTa ufa Pabb Site Sled Fibs- Plan is <br /> Worriatia Gallons Gallom Tanks Coo- Con- glass <br /> New Existing orae snaoted <br /> Tanks Tanks <br /> P47 ❑ ❑ ❑ ❑ a <br /> VRL Rey Statrsoeat <br /> .twsttme forisadlatiow Ofdabawa oa ibe atttebed <br /> Naaae (oro <br /> .sae. taode / e y �1— Ala <br /> Yto/ <br /> iR co..ty/Depatrt eot the Vale A9 <br /> at <br /> Apptovsd 0 Owns Given Initial Adverse /y saw Fee) A "/ <br /> Ddamme o�U <br /> X.Cowdkiown of Approval Mensews for Disapproval: i <br /> BURNS 6 2 <br /> ZO/V' UN7Y <br />