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Sir c(,and Buildmes Disision C,mot. <br /> ` <br /> _J111. 11 ashin�lon:Ice. P.0 Bus 'I n'Isconsln NIadIWif k1l 5 ' - "l o? <br /> � Jun nary I'ermn N <br /> Department Of Commerce Iritis)_'ho-3151 44-5 e7 9umher(1,be IiIIrJ in by5 <br /> Sanitary Permit application "aie ria "Amb<r )j� <br /> In Accord%i h Comm 83 '-1.Ills. Adm.Code,personal ml�mnution you prop idc W <br /> may be used for secondary purposes Pmacy Law.sl i o4(I Awl <br /> Pnye❑Address ii1 Jii fercm than niubny aJJressi <br /> I. Application Information—Please Print All Information a"71, <br /> Prupeny Ow ncrs NamJ`}�e "' 33.. OCCa'. a mgr �r�[� <br /> �- Parcel s Lot i Block x <br /> t;nor oIY-9o3s=a-3a�� <br /> Prupeny Owmcr s\lading Address <br /> Property Location <br /> at c47C 4,*/tjr Ave w <br /> Coy.SP e Phone Number tale Zi CodN NW ':. Section d` <br /> WC.4j'cev w1- 'r9 TT Iclrcl- <br /> e) <br /> 11.Type of Building(check all that apply) T "3q N. R 14 E oc <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Subdicisiun Name CS,11 Number <br /> ❑Stile <br /> Commercial-Describe Use L/OY`s 0')'f F,,n,sk" Ad J <br /> ❑Stale Owned-Describe Use ❑Cu ❑Villa e v� <br /> Y_ g .Township of �6Cnmh <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> , New System ❑ Replacement System ❑ Treatment Holding <br /> Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Penns Res AwnIssuedious Puma Number and Date <br /> ❑ Change of ❑Permit Transfer io New List Prev <br /> Before Expiration Plumber <br /> Owner <br /> IN'.Tv e of PONT'Scstem: Check all that a Iy) <br /> ,K Non-Pressurized In-Ground ❑ Mound>?J inof suitable sod ❑ Mound<'a in.of suitable sod ❑ At-Grade ❑ Single Pass Sand Filter U <br /> Constructed Reiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filler ❑ <br /> Recirculating Svnthemc Media Filter ❑Leaching Chamber ❑Drip Linc ❑Grasel-les;Pipe ❑Other(explain) <br /> V. Dis crsal/Treatment Area Information: <br /> Design Flow igpd) Design Sod Application Ratel gpds tl Dispersal Area Required(if) Dispersal Area Proposed Ist) System Elevatin <br /> 5-0 17 6u3 6 y8' W.J. �rPe' <br /> 4. <br /> %l.Tank Info Capacity in Total NumberTli-* /owe✓ <br /> Manufacturer Prefab Site Sic el Fiber <br /> Gallons Gallons of Units Plastic <br /> New E.auting Concrete Constructed Glass <br /> Tanks Tanks <br /> Scptic of Holding Tank <br /> /Oo0 /moo .� SE,rw x <br /> Aerobic Tmaiment hint <br /> Dusmg Chamber t <br /> N11. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POUTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature bIP h1PRS Number <br /> ,s � Business Phone Number <br /> lese-le- �O �'/1 S t'it; <br /> Plumber's Address(Street.Gty,State,Zip Code) �6 6"4•/,f <br /> of 7 76 d ff.. i ,s— <br /> x'111.Counts/De artment Use Only <br /> �4ppren ed ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued`/ IS]L.0 ignat o Stamps) <br /> Surcharge Feel 'Z' �T J 19�j .d b7 <br /> 00 <br /> Owner Given Reason for Denial sJ(f <br /> IS.Conditions of ApprovaliReasons for Disapproval <br /> AnAch compicie plan,(to the County only)for rhe ssstem nn paper oat Icss than a1.2 x I I inches in sial <br /> SBD-6398 (R. 01/03) <br />