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Sit,cly and BuilduLi Dmsnm Gmni, �[ <br /> air _III . 1l'ashmelon Avc. P.0 Box, 71 o' Bts,Yn Lo �f- <br /> ` im1�d�li(6 �1,1 5:;II' - ;16-1 jun mar. I'ennn <br /> iseonsn NNwnher Iia be tib <br /> tilled m ..Co m <br /> Department of Commerce usl_nn-,I51 57 <br /> 71 <br /> Sanitary Permit Application Stale Plan ID `°timber <br /> In accord with Comm 83-yl.Nls.Adin Code.personal mfomtanun you pro%idc V�J <br /> may be coed Ibr secondary purpow,Privacy Law,sl j Oat I NnU Pnticcl Address Ill different rftan nmuihng aJJro;l <br /> I. Application Information-Please Print:UI Information <br /> Pmprny Ovvnef;Nan'c Parcel a Lot i Hloek a <br /> 70- <br /> "n Waj'pj vo el 02 U- K333 -03- <br /> I'nmpersy Owners Milling Address Properly Location$b(o0 Gen calx St. rtl6 <br /> C ny.Sale ZipCode - •. Section 33 <br /> Phone Number <br /> /acne MAl.. 6"S43k 763-78'f-9351 (circleone) <br /> 11.Type of Building(check all that apph) t T 40 N, R A8 E or61 <br /> ,Q I or 2 Family Dwelling-Number of Bedrooms Os Subdicision V. <br /> CSSI Number <br /> ❑ Public Commercial-Describe Use L®1 to �/a 3 P. <br /> ❑State Owned-Describe Use ❑C"y_❑Vmllage XT~ship of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line R if applicable) <br /> New System ❑ Replacement System ❑ Treatment Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Penna Re%islooLut Previous Perm"Number and Date Issued <br /> rC] Change of ❑Penna Tran;ier to NewBefore Expiration Owner <br /> 1%.Tv pe of PONTS System: Check all that a Iv) <br /> .OI Non-Pressurized In-Ground ❑ Mound>24 inof suitable soil ❑ Mound<24 in.o(w"able sod ❑ At-Grade ❑ Single Pass Sand Filmer LJ <br /> Constructed N eiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Symhctc Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel less Pipe ❑Other(explain) <br /> crsal/Treatment.Area Information: <br /> Deign Flow Igpol Design Sod Application RamelgpJsl) Dispersal Area Required(sl) Dtipersal Area Proposed(sl) System Elevation <br /> 3 �� 7 41 9 Z/Sot 9A •7 <br /> V11.Tank Info Capacity in Total Number Manufacturer Prefab Site (eel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Exrstmg <br /> Tanks Tanks <br /> Septra or HulJmg Tank pop gD0 / <br /> 4 .S�L/9W X <br /> Actable Treatment Unit <br /> Dosing Chamber <br /> X71. Responsibility Statement- 1,the undersigned,assume responsibilitv for installation of the PO%k T$shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP AIPRS Number Business Phone Number <br /> 14k- f/a F;n s ?,e� <br /> Plumber's Address ISneet,City,State,Zip Code) <br /> 776 0 Hit—y 3S 141-eAsfar Wr 54893 <br /> Alll.County/�e artment Use Onh <br /> Approved ❑ Disapproved Sanitary Pe <br /> Fee(includes Groundwater Date Issued Issu.ng. Signature I amps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I Jaf4Y <br /> J � 200¢' <br /> BURNEr C <br /> ZONING UNry <br /> Attach complete plans(to the Counts onl))fur the system on paper not less than 81:2 x I I inches in site <br /> SBD-6398 (R. 01/03) <br />