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I <br /> r.Rta�trt r.ca.>nri.��v SaF r, �d Build D r,tsn r , <br /> �„ p a Ltil G/hA dison P/[ 53707-7(62Uox7tOl Ia NNC� <br /> ,�h��5p�y "� 0 <br /> r <br /> Is�JRs.�� Yir/ S uui�y t.,tr. Nnmb.,r(,00 fii.,o ui by CoJ—.— <br /> Oa artment of Commerce <br /> set 1. .:,,-,a rt •,.t <br /> In accordance with s.Comm 53.2](2),Nrs Adm.Cod anbmrssion of this forru m the approprmfe 6v i naseAtai {_���I�� �J <br /> unit is required prior to obtaining a samtary permit Note Application foams for state-owned POWTS are P gicct Address(if different than trailing arlm'ess) O <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> ur Apes iaccordance with thePrivacyLaw,s. Stats. <br /> I. Application Information <br /> —Please Print All Information y n C <br /> tVo—rU0` <br /> Property Owner's Name ) Parcel#0 7•d b •40-/(r d 7r.3 p.3 <br /> G C�, 3�aa I mB0_f7//0� <br /> Propetty Owner's Mailing A dress Property Location/ <br /> 6 953 ' G e C // G (#oot.T:nr �NG aF <br /> City,Slate Zip Code Phone Number <br /> �560 '/4, SW Y., Section <br /> bnbur 6, X_ ✓ry6133 T�QN; RJ�EonCJ <br /> II.Type of Building(check all that apply) Lot# <br /> .�l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block u <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> El State Owned-Describe Use CSMNumbcr �D Village of <br /> y� Town of aa'CIA n�• <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if applicab7) N <br /> D New System D Replacement System reatment/Holding Tank Replafication to Exis[img System(asolainB. ❑ PermitRenewl D PrmitRevisin ❑ Change of Plumber D Permieanut Number and Detc Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/DeAce: (Check all that apply) <br /> D Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in.of suitable sod. D Mound<24 in.ofsuitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain)___ <br /> V.Dis ersaVl'reatment Area Information: <br /> Designn��d) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> o.s 900 900 9Z.00 <br /> VI.Tank into Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks w o V G _ b n +' <br /> Septic or Holding Tani; 00 <br /> Dosing Clamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) !/ - Plumber's Signature MP/MMPyRS Number Business Phone Number <br /> /0."elG4v /J <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ?76oe S u/c�s�ri w< S-5'�r3 <br /> VIII.Cozen /De artment Use C)rrl <br /> Approved ❑Disapproved Permit pee Date Issued Issuing Signatur <br /> ❑ <br /> S <br /> Owner Given Reason for Denial ,,/ .2/ j <br /> IX.�Co"nditions of Approval/Reasons for Disapproval <br /> 1Flryace'..r,Jf of ,)loan Fj-*a 0T 'V 1�er_ <br /> Amach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />