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Snfely end Aaildinps Division Cowry <br /> 201 W.Washington Ave.,P.O.Box 7162 (J u<F' � <br /> Y�sm�� <br /> Smbd, PdmitNT(tohefiled in byCo) <br /> S 25arce -. .. <br /> Sanitary Permit Application Sam Plan ID Num <br /> ber <br /> In accord with Comm 8121,Wo, Adm.Cody personal infom.tion you provide — <br /> may be,used for secondary purposes Priveey law,315 NilXm) Pitied Address(Ifdlffemnt than m®ling address) 9 <br /> -) <br /> 1. Application Information-Pleats Print All Information <br /> POwner's Nemp Parcel% Lo[q/6 N7d6tllmkp 9 `v 1 <br /> , Bald ohA sdr OL0- 9Zso -oq J00 <br /> propcdy Owner's hangs&Addends - Proper,Location <br /> 7983 :R.- 3t mit, 56 v,, Setop <br /> City,Sam,p Zip Chile Phone Number <br /> JNw V14I- I/ , SY830 T�0 N, —/ rcleoq <br /> R Eor <br /> III Type of Buil iog(cheek all that apply) <br /> bbl ort Family Tinseling Numbernfbedraams 3 Subdivirmn Name CSMNo bcr <br /> ❑PublicKommelcul-Descdbc Usc <br /> DState Owned-Ues'in,to Use _-_- ❑City-❑Village&Tomy11 all/CI/1 Ph <br /> III.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A" 11 Nov,System epacennnt System ❑TheaunrnNllolding Tmi4 Repa.ement Only ❑Faber Modification to Existing System <br /> R. UPermit Rrnewxl ❑Pamir Revision ❑CheoRe of ❑PnmitTmmfer to New Lisl Pmvinus Permit Number end Date avian <br /> BeforcUpimtian Plumber Owner <br /> IV, <br /> Type of fss[) S System: Check all that apply) <br /> Xim-Preentiadln-Ground ❑Moved'241n.ofs'ambleval ❑Maand<24inofsuiteblesoil ❑AI-Dade ❑Single Pass Send Filler ❑ <br /> Consvuded Welland ❑Pasymiredl,an{r�•rmasd ❑ Bolding Tank ❑Prat Filter C1mtm <br /> Aemmm Trent Unit ❑Recirculating Saml Filter ❑ <br /> Regirculating S"fi esc Media Filler /J+.caching Chnmber ❑Drip Line_ ❑(nivel-I 'Pipe ❑me explaa) <br /> V.Disemal/freaterect Aro l.15rnlation: C' 3 X Y- a � Clc— r F^ 0 <br /> Design Flow(gpd) Design Soil Appl Fee bacillasr) Dis'pasel Area Required(at) Dispersal Are.Proposed(sf) System Elevation <br /> V SU 1 a —7 vV 9 9 y. >o <br /> VI.Tank Info Capocily in Total IshiiManufactuv Pmfab Site Steel Fiber Plastic <br /> (gallons Gallons ofllnits Concrete Comtmeed Gass <br /> New E-.9 <br /> Wu T®ke <br /> seplm stems Tmh 000 l 37-6d, 2c Ail/-a k <br /> Aacbm Tocantins Uwe _. <br /> Pon,Chamhor <br /> VIL Rea .sibilit Sta[ement-I,the untlen�rled,aaume responslbmty for the smith.PUW'ISahowoginumeachcdpla.a <br /> m <br /> for Noe[Print) lumber's Signemre umber Bwiness Phone Number <br /> �Ctcc�u.E yd,w "t.S ;� ZZ.2-57ZL X77 Z-0-Z- LI <br /> Plumber's Addten(Sired,City,State,Zip e) <br /> D'4 ;""__/Lc,Ckl <br /> VIIL C..n /De icrtment Use Ong_ <br /> Smv Permit P.(iacadee Goundwear Date Lamed limits iSim. Stamps) <br /> Approval ❑LinePPmved Surcharge Pee) $ .� f <br /> ❑Owner Given Reason fm Denial IRA <br /> "so <br /> O` <br /> M.Conditions of ApprmepReaso.s for Disapproval <br /> AlMheampleR phwllo lheCmey oolY)raa roe ayalemm PParuutkae lWv 8V2xll lrcbm iea�. -.. <br /> SBD-6398 (R. 01/03) <br />