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AlkCommerceml.gov Safety d Buildings Division County <br /> a 201 W.Was nglon Ave.,P.O.Box 7162 13ke n e �- <br /> i seo n s i n Madi tn 'n,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De'Porterst of Commerce 4-Z s "l'4+ <br /> Sanitary Permit Appli tion State Tramaction Number <br /> In accordance with s.Comm.83.21(2),Wie.Adm.Code,submission of this form b the appropriate govemmeNal <br /> JQ <br /> unit is required prior m obtaining a sanitary permit Note: Applicati forms for ante-owned pOWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> Purposes in accordance with the PrivacyLaw,s.15. I m,Stan. At N C aLA) KOA'V <br /> L Applicationshtformation-Please Print All Wotmation ln g 1`00 .57' <br /> property Owner's Name <br /> Pu«I# <br /> /Caf art n 020 922S oz con Silc 2- <br /> Property Owner's Mailing Address t 9225 03 000 81 i. <br /> Properly Loatirn <br /> �y EA IC /�oG� L6n Govt.Lot <br /> City,State Zip Code Phone Number <br /> Yy Yy Section 7� <br /> stern v/ve (/•A, <br /> .10K/S 703-965-330(8 T �D N R / circe o= <br /> IL ype lktilding(check aB dutt apply) Lot# 2to E <br /> I or 2 Family Dwelling-Number of Bedrooms J. f d Z 0 Subdivision Name <br /> SfifL't1tIE5 �STitTFs <br /> ❑PublidCommeroial-Describe Use Block# <br /> 2 ❑City of <br /> ❑Stan Owned-Describe Use CSM Number ❑Village of p <br /> 13 Town of OAK/and <br /> IIL Type of Permit: (Check only one box on line A. Complete e B if applicable) <br /> A. New S <br /> yatem ❑Replacement System ❑TreatmrnVH ' g Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ChaageofP ber ❑PermitTramferto New Lut Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWYS S tem/Com onenNDevice: Qreck a6 tlmt apply) <br /> ,q Non-pressurized In-Ground ❑presso 'zed Ia-Ground ❑AbGode ❑Mmmd>24 in.of sudable soil ❑Moond<24 in.of suitable soil <br /> ❑Holding Tank ❑0therDispersal Component(aplaiu) ❑Pretreatment Device(explain) <br /> V. ersaVTreatmmt Ares Information: <br /> Design Flow(gpd) Design Soil Application Rste(gpdsf) Dispersal Required(sf) Dispersal Ara Proposed(sf) System Elevation <br /> 41-5-o . -7 a ti.3 6 v 8 401 ..1 <br /> VI.Tank Wo Capacity in Tot 1 #of Mawftclurer <br /> Galloonp <br /> New Tanks p��Tanks Gall Units w a $ b <br /> Septic or Hoi i%Tank w <br /> Doting Chamber <br /> VII.ReapOnability Statement-I,the undenigo¢d,assume respooaibil ty for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Four) PhtmbWsSi store <br /> � MP/hMRS Number Business Phos Number <br /> /Z lGle- f/021n'7_f /24-e-l��A '4 it e6e,-4/.t`� <br /> Plumber's Address(Street,City,State,ZIP Code) <br /> a 7 76 0 A/r 3.5 6'41e6s><e- Lfi�g 5e s-�3 <br /> V111.Coast /De artment Use Ont <br /> Approved ❑Disapproved Permit Fee Dan Issued Iaswm Si <br /> ❑Owner Given Reason far Denial S �5(7� 11 /'Sc'q <br /> IK Conditions of ApprrovaVReaso a for Disapproval <br /> Attach teromplete plazafor the ryatem and urban the Camay tidy m paper sera les Wo 61rs a 11 inches n siae <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />