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sit c( and Fiwldtr_s Di,l,Iom C�nuiL <br /> 'IIIk1'. 4k'Ishlnefon.Ate. PUbac7ln_ Ur <br /> isconsintiddlulll - Ib_' janilif•. Pcnnn Number Ill.be tilled I <br /> Department of Commerce Ibtlb)2on-3151 651/ m <br /> Sanitary Permit application State Man 11 Number <br /> In accord with Comm 83 2I.N Is. Adut.Code.personal Information you prof idc <br /> rav be u,ed IM.co,nclary purposes Pru ac) Law'.;I i tail tCPO <br /> luU W <br /> Project Addre,,III different than trading add,,,,) <br /> I. :Application Information—Please Print.All Information <br /> Pnipcn y <br /> Owmers Nante <br /> Dfv 1-.-hNcr' <br /> Parcel a Lot a Block a <br /> 9i�s <br /> Prupen}Owner's AlJilmg Address OU odd goo <br /> D 7 Pruperty Location / _ r � CSM U/i <br /> r7" Liv �-U �•S <br /> l ity.Stain 2i CedeZ_ <br /> P Phone Number Section'' -�• <br /> i al"i1jtar W,- i5 /,!;X— ems �J++rete , <br /> y11.Type of Building(check all that apply) T N. It �✓E o� <br /> ya I or 2 Fundy Dwelling-Number of Bedroom; Subdn i;mn.Wine CSM Number <br /> ❑ Public Commercial-Describe U;e r r' <br /> ❑ <br /> Site Owned -Describe Use ❑City_ Anlage Mownship of (fir <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ❑ New System Replacement System ❑ Treatment Holding Tank Replacement Onl <br /> y L-1 Other Aludniwuon to Existing System <br /> B. ❑ Pcnnn Renewal ❑ Permit RevtilonChange of ❑Permit Tran;ier to New List Previous Permit Number and Dale Is;ued <br /> ❑ <br /> Before Expiration Plumber <br /> Owner <br /> IA'.Tv c of P0%%TS Ssstem: Check all that a ly) <br /> %Non-Pressurized In-Ground ❑ Mound>24.n.of;wublc sell ❑ Mound<24 in.of,moble Wil ❑ At-Grade ❑ Single Pass Sand Filter LJ <br /> Constructed Actlind ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Symhemc Alm..Flier ❑Leaching Chamber ❑Dnp Linc ❑Gravel-less Pipe <br /> V. Dis crsal/Treatment Area Information: P ❑Other leaplmnl <br /> Design Flow Igpol Design Sud Application Ratelgpd,l) Dispersal arca Required IslJ Disperrrssall Area Proposed Ill) System EE 9!57-/ <br /> Elevation <br /> 00 <br /> fo Capacity•in �2 q % /Z <br /> Al.Tan <br /> Total Number Minufaclurer Prefab Site <br /> Gallons Gallons of Units Steel Fiber Plastic <br /> New, Eaumna Concrete Constructed Glass <br /> Tanks Tants <br /> Septic or Holding Tant 006 <br /> Aerobic Treatment LastC V <br /> Dulling r <br /> Chamber 750 75D L {Ax r <br /> %7111.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POAATS shown on the attached plans. <br /> Pluyyyber's Name I Print) Plu cr'i Sign r AI <br /> n <br /> �•,� ignAll PRS Number Business Phone Number <br /> /10 r zzs mss/ 7 <br /> Plumber';Address(Street.City,State,Zip Code, <br /> 27 w tae <br /> A'11 .CountwDe artment Use Onh <br /> Approved ❑ Disapproved Sanitary Permit Fee Iincludes Gruundwatcr Date Issued Issu.n ent Signal (No Stamps) <br /> ❑ Surcharge Feel f1- W,50 <br /> ` <br /> Owner Given Reason for Denial Yf' `JO -'!p <br /> I\.Conditions of.Approval/Reasons for Disapproval <br /> FjU SPVC, W G Con VlDLT>rl) - o FT6C_-r0A. A T By TH16 AM 71ia10 of A `lifer ftp: <br /> k)141cFt �JM�S TO THE NIU SKARJ S'C.AfrC TWK. WITH A .7h66L Ay00-z2 FllT6L <br /> Alraeh complete plans Ilo the Counts nnl,I fur the suer on paper not less than III.I a 11 int in sia <br /> SBD-6398 (R. 01/03) <br />