Laserfiche WebLink
Safctc and Buildin_;Dni,ion C"roil, <br /> e I/VcO,Isin X171 1C. 1Cashmgtun:lte. P.O Boy 71o_ p <br /> Department Of Commerce (6uSj26n-3151 �Jnlur. Pc"lilt Number Ito be tilled in b.Cot _ <br /> Sanitary Permit Application $lair ' l j nC� <br /> In accord with Comm yJ 2 I,is is Ad <br /> ( l <br /> . m.Code,personal Infurmition you prop tdc fVCC\ll <br /> may be used for secondary purposes Pnsacy Law.,I i dal 1 ilnu <br /> Project AJdrrea ufduferenl IhJ""'ailing Jddrem) <br /> I. :lpplication Information-please print All Information (111) <br /> � <br /> Pnipeny Ocsncfs Nano q aelir.-K--t-�e- <br /> Q Ite U rn.i��6r f Parcel a �'-"���Lo�t p t G <br /> Block a <br /> 1'"'Pcny Owner's Valhng Address O 1 -q1 -7S70 600 <br /> S ' d 0 7Q Sf�><� S Properly Location <br /> L Ili,State <br /> S2,- ere%x //-r Zip Code Phone Number ti <br /> Sccon <br /> Fa w1 s-y � — <br /> I1.Tipc of Building(check all that a ad 7S-- '183—%3d7 Iclrcl j <br /> PPh-) T Z/Q N. R f_S'E ow <br /> I or?Family Dwelling-Number of Bedrooms <br /> u <br /> Subd's 'on Name <br /> Public Commercial-Describe Use J /,, CS��I Number <br /> ❑Stale Owned -Describe Ust h`� �w B Trw- <br /> I11.Type of Permit: (Check only one boa on line Comple[e line B if applicable) ❑CifY_❑billagr BTownshlp of <br /> �New System ❑ Replacement System <br /> ❑ Treatment Holding Tank Replacement Onl <br /> Y Ll Other Modification to Existing System <br /> B. ❑ Permit Renewal <br /> ❑ Permit Res own <br /> Before Expiration ❑Change of ❑Pennn Transfer to New List Prey mus Permit Number and Dale Issued <br /> Plumber Owner <br /> 1�•Ts c of P01,1TS System: Check all that apply) <br /> Non-Pressurized In-Ground ❑ Mound>-'a inof suitable sod ❑ Mound<14 In.of,unable soil <br /> Constructed wedanJ ❑ Pressurized In-Ground ❑ At-Grade ❑ Single Pass Sind Filter ❑ <br /> ❑ Holding Tank ❑Peal Filler <br /> m elic Meda Filter EJ ❑ Aerobic Trraonent Unit ElRecirculating Sind Filler <br /> Recirculating S. <br /> ❑Lea <br /> Dis crsaliaching Chamber ❑Drip Line Gravel-less Pie ❑ <br /> �'. TreatmentAreaInformation: P Other <br /> Design Flow Igpd1 Design Sud Application Ratogpd,fl Dispersal Area Re uired 1st <br /> 41-0 7 4 ) Dispersal Area Proposed(s) Syslrm Elevauon <br /> a ��/3 <br /> VI.Tank Info Capacity in Total &191 9y 9up"e- ka zl sizer <br /> Number MJnufaclurer <br /> Gallons Gallons of Units Prelab S11C <br /> New Existing Concrete Steel Fiber Plastic <br /> tanks Constructed Glass <br /> Sapoc or Huld,ng Tank Tanks <br /> /O ae /000 <br /> Aerobic Treatment Unit Jkw W v <br /> Dosing C hambcr I <br /> %II. Responsibility Statement- 1,the undersigned,assume responsibility forinstallation of the POW TS shown on the attached plans. <br /> m <br /> Plumber's Nae(Pnnt) <br /> Plumber's Signature?2G i( NI M1IPRS Number Business Phone Number <br /> Plumber's Address IStrerl.Gt �T ,< ����'r/ 7/s— el IS—y.Start,Zip Calc) <br /> .-4 -7760 Hwy 3.S- Lu eh w <br /> VIIL County/De artment Use Only r� X93 <br /> ,Approved ❑ Disapproved Samluy Penni, Fee(includes Groundwater <br /> Surcharge Fee) �je Dale Issued Issc.n Signature lamps) <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of ApprovalrReasons for Disapproval a`r(OC,�(,/ <br /> I <br /> JUN 1 Q 2804 <br /> BURNETT COUNTY <br /> Ankh cumplc le plans Po'he Counh only)for the ss stem nn a er no NTNG <br /> P P 1 less Ihan a1:2 a l l inches in site <br /> SBD-6398 (R. 01/03) <br />