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09/18/2008 13:22 3492166 B C ZONING PAGE 01 <br /> � B..R�.a SANITARY PERMIT APPUCATION YATftJAQ� � <br /> rr'7aw7 In accord with ILHR 83.05.Ws.Adm.Cade WtATE L" <br /> NR MR <br /> -,Attach complete plane(to the county copy only)Tor the system.an Paper not lase than ❑cn.d<ev o 0MIWA awc'aun <br /> a%x 11 Inches In site. <br /> -See reverse skis for Instructions for completing this appllcation. STATE PLAN I.O.MJMBER <br /> 1. APPLICANTENIORMATNIN-Rim F1IINRALLINFORMATION. <br /> A. rRoPER1Y LOCATION <br /> R� <br /> E or <br /> awNaaa LOi4` (p <br /> CRY 8TA W PfIO1Pi BUBWVIam NAMEORCBMNHU�MBBER <br /> B. TYPE OF BULOrM�fi: one)e) Blots Owned _ QI.C,C+ R [(j� �• <br /> ❑Public 1'X 1 or 2 Fam,Dwallln04of bedroomsc" (� 9/j� <br /> RL OULLUM USM (ff bWldmg type is Puwlc dneok,Il tw apply) �� JDa O1`"" <br /> 1 ❑ Apt/Go <br /> 2 o Assembly Hall B ❑ Medical Facility/Nursing Home 10 [:3 Outdoor Recreational Facility <br /> 3 ❑ Campground 7Merchandise: Sakia/Repalrs 11 0 Restsurant/Ber/Dining <br /> 4 Church/Bchool 6 Mobile Home Park 12 0 Service Station/Car Wash <br /> 5 Hotel/Motel B ❑ OlRce/Factory 13 ❑ Mar.. SpeCtfy <br /> N. TYPE OF PERMIT: (Check only ans In ons A. Check lisle B it appikleebk) <br /> A) 1.❑New 2. Replscament S. ElReplacementof 4.❑Raconnection of 5.❑Repair of an <br /> "tamSystem Tank Only Existing System Existing System <br /> B ❑ A Sanitary Permit was previous Issued. Psrmlt# Data Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distributlon Experimental Other <br /> 21 H Mound 30 ❑ Specify Type 41 ElHoldingTank <br /> 11 Seepage Bed <br /> 12 Se�p�geTfench 22 in-Ground 42 <br /> 18 SeepapePit Pressure 43 Vault Privy pit Privy <br /> 14 System-In-Fill <br /> V1. AESOWTION SYWM DWORMATM <br /> 1.GALLONS PER DAY 2.ABBORP.AREA 3.ABBORP.AREA 4.LOADING RATE 15.PERC.RATE 16.SYSTEM ELEV. 17.FINAL GRA <br /> t REau +L) (w *<) farm�oq.fL) (Min lndl) ? <br /> q16 1 S .� Ft Fillet <br /> VM TANK ( Tetpl #of MenuheNrar a Name Prefab. Cin Steel glis°N' Ruth fir' <br /> MPORMATION Naw Gallons Tamm act urse <br /> Tanks <br /> cod <br /> T mer <br /> rT- <br /> VS. SPONMIDNJTYSTATEMENT <br /> i,the undersigned,seaums responsibility for ke Wlatlon of the onsite sewage system shown On the AascAw puns. <br /> rwoora HE (Pnlla: RYmeers 8lgnebRe: IMPIMPAGINNO: auglman Ph*m Number. <br /> PIUMbW AddNW((JCA♦ <br /> OL COMMIDEPART r <br /> DesppmNb remit1wpawwwwo <br /> //Qy ga No enema) <br /> ❑Owner O)vw InNal 9 los.Co /'IV <br /> X COBOIrlDMOFAPPROVAI/REAS MPON DISAPPROVAL <br /> 88D4feaponmrly P"?)(11.11/aS DIBrRMV Ml Original to County.OM CORY To:3e101Y A Buodlegs bMON4 Owner,Plumber <br />