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COstMf19fC9.wl.gDv Safety and Buildings Division f�� Camty <br /> me <br /> It., hI1011Onof�n 201 40OW �OUNN .,,,ypermit <br /> �uNumber(to Wfilled m by Co.) <br /> `tc� 5-32 z <br /> Sanitary Permit Application StwsTNumb` <br /> In accordance with s.Comm.83.21(2),suis.Adm.Code,submission of this two m the appropriate governmental C/(�L ttr ics"> <br /> unit is required prior to obtaining a sanitary permit. Note: Application firms for stat vrncd POWTS are Project Address(if ditfetent than mailing address) <br /> submitted to the Department of commerce. Personal information you provide may be used fm secondary <br /> in accordance withtheivacy few e.15.04(l stab. III 5b .SfaEc Kat �('U <br /> [. Application -lien Informatloo Please Print All Information <br /> Property Owner's Name '' II <br /> Car r,l OediN <br /> Property Own 's Mailing A p / Property Location <br /> ago ale lid • /7S <br /> city,S Govt. t <br /> Zip Cade Phone Number ���Y, J C Y., Section ztP <br /> rrea e vi c 37 715- - 3x7-8Y63 �f�vc leo <br /> Q.Type of Building(shack a6 that apply) l.m a <br /> T�N; R_._[�j_Eo� <br /> ®1or2Family Dwelling-Number ofBedroom; Oz Subdivision Name: <br /> �—/ — <br /> ❑PublidCorrmrerBlock# <br /> cial-Dascribe Use ❑City of <br /> ❑State Owmed-Describe Use CSM Number ❑Village of �-� _ <br /> ®TOW of / /fhci� <br /> III.Type of Permit: (Check only one box on Use A. Complete Bne B If applicable) <br /> A. ❑New System Replacement System ❑Trooment/Hoklm <br /> g Task Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Phmber ❑Permit Tmmsfer to New List Previous Permit Number and Date Issued <br /> Before Exp ntosm 0wmc <br /> IV.Type of POWTS S m/Com nent/Devlce: Cheek ad]that <br /> a Non-Pressurized In-Grouad ❑Pressurized In-Grotmd ❑At Cra�d'(o ❑Mo/m�d>_24in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(cxpla n) J ITT ��n I\ ❑pretreatment Device(explain) <br /> V.DispersaVfreatmerst Area Information: <br /> Design Flow Igpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Disperse)Area proposed(al) .System Elevffion <br /> 3 07 8. S 9©.Soa�9t '00 cc ( <br /> W.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units g <br /> New Taub Existing Tanks <br /> 6 U iz <br /> SepecmHoldmg Tack /OO rt )i? _ n(Ye <br /> Doses Chamber LnQV Q? O <br /> VQ.Responsibility Statement-f,the aaderslpred,mstune toahBadm of the POWTS shows on the attached plans. <br /> Plumber's Name(prig) Plum MP/MPRS Number Business PhoneNumber <br /> er 4rI San/ 32'-45 71s-6S3 asm <br /> Plumber's Address(Street, Ill,State Zi Code <br /> s e, bJt�,3 <br /> Z SY <br /> VQI.Conn eat Use Only <br /> Approved 1 ❑Disapproved Permit Feec Date Issued Iasuimg Signature <br /> 11 Owner Given Reason for Denial E3�59P A AM.IL10 <br /> UL Conditions of Approval/Ressons for Disapproval <br /> l, <br /> Ahad to turpkr plus,tar tat sysrn and aebark 0 the Comaty only art paper rot ler do 81/1 x 11 tnehn to qm <br /> SBD-6398(R.02/09)Valid thru 07111 <br />