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r <br /> ' Safety& Bwldings log iu,m <br /> Sanitary Permit Apr%H�Qtir_,n 3111 µ'. R'ashl", <br /> Yll IS([� Ali <br /> ` R In accord with Comm 83.2 1,W is.Adm. Code <br /> • comrr,a•r,c Personal information you provide may be used for secondary purposes (Submit completed tbrm it,', <br /> (Privacy Law,s. 15.04(I)(m)) <br /> Anach com tete Elans(to the coon co- o: - - ----' -- -- ----- `--- -- ^..!;_x 11 inches ir.size. <br /> State S P Nugtbsr O k if ion to previo applicatieQ State PI-an 1.D.Number ( n <br /> 6 U,L n t✓ `J <br /> I. 1,pplicatiun Information -Please Print all Tnfnrmarinn J Location.- <br /> Property <br /> ocation:Property Location ---..— -1 <br /> _ A1EI141E 14.S // Ir34\ <br /> %aoing Address Lot Number ilk,. -....,.. <br /> /dl047 e..4L. 2d- 4 <br /> - - Zip Code Phone Num6er Subdivision Name or CSbI\wni, <br /> II l\ c of Building: ❑City <br /> Dwelling-No. of Bedrooms: *2.- ❑Village <br /> C"ommercial(describe used:.. J21'1'own of/2,46KJ ned <br /> Ili '1c pe of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RoArAl "A <br /> „ ------------ <br /> Nety System 2. )<Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Nmnbet(.) <br /> Svstem Tank Onlv Existing System I OZV-3 -01/00 <br /> B) Pcnnil Number �Dalc Issued <br /> ._. .� �,amtary Permit was previously issued <br /> 11 . T, e of POW'T System:(Check all that apply) <br /> X�' r-7ressunzed In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ;t-�zae ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> Dis ersal/Treatment Arca ;uL,..,,. <br /> gpdi 2.DiL <br /> 3.Dispersal Arca 4.Soil Application S.Percolation Rate 6.System Elevation Fm.J� ,anr 1 <br /> ReqProposed Rate(Gals./day/sq.-R.) (Min./inch) Plcvai ui <br /> Zoo 4.3 z.- Moe h Ugys 9z.i-99.ir <br /> v'I "tank Capacity in Total q of Manufacturer Prefab Site Steel Fiber "I:c:• <br /> I Int [rnuati„n Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted ' <br /> Tanks Tanks <br /> S.7'H7 {} O® 800 DO I oslC/7c.� <br /> C /Z~ Abt6 ❑ ❑ ❑ ❑---1 <br /> 11 Responsibility Sta%i:iti:; <br /> [i _ ur.dcn[urad.assume resoonsi for' stallatio f the POWTS shown on nached plans. <br /> ignat o stamps): MP P o. Business Phoneniitii .Xuinhri <br /> IC kXC a�y�7i <br /> 715-635-7x82 <br /> HI Counr.,Department Use On!-; <br /> Disapproved Sanitary Permit F (Includes Groundwater DateJ61 <br /> iss 1 Sig[ <br /> Owner Given Initial Adverse Surcharge Fee) ,� 1161 Determinarion U <br /> I V (Cuudi/tions of Approval/Reasons fur i isappruvalt: 1 / <br /> Ins lGt /�!J D"f `l�tt•ut s'.WV' _T P71ee�T Lu1✓Frnr J pc ` <br /> Se+ <br /> IV- <br /> //V TY <br />