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Sit and &uldul_, Dnlslun Gnuu, <br /> 11 ' ll'J,hmgton Atc. P l) Bo, 71 t1 eArn eft <br /> VOnsin MadiNoll.11 11 j - 102 <br /> �JIIIIJf;. Pcnnn Numhcr Iw be illicJ In b.Gi <br /> Department Of Commerce (ndy)-'nn-3151 �D� <br /> Sanitary" Permit .Application Sidle I'll" ID Nunibcr <br /> In accord wllh Colman 83 '-1,ll is. Adm.Cute,personal m6mn.mon you pro,Ide <br /> may be mcd for,rctin dary purpose,Pnsacy Law.i I i 11411 hall (� <br /> Paged AJJrcu nl JIi(ercm Than luadmg JJJrc,si )LJ <br /> 1- :xpplieation Information_Please Print All Information <br /> Property O,wcrb NJnle <br /> [ 10$1y /Qke Rd. <br /> Parcel a Lot a Hl,ick <br /> Joha <br /> Fever 0d �- �//,Of; ook- ice <br /> I'ropeny O,mer;M1iailmg Address <br /> Prupeny Lucunm <br /> /S��/ D�exe( w4y <br /> C ny.Slate Phone Number <br /> Zi P Cude Section s <br /> MN -5' / 4 `Sat -std3- >03I <br /> 11.T3 Pe of Buildin °l larcic,>trl <br /> pprr g(check all that apply) T �/O N, R /k E p <br /> ry l or 2 Family Dwelling-Number of Bedroom,, 00� Subdi,ision Name <br /> ��-�yy ./ CSI Number <br /> El Public Commercial-Describe UOx c LOT e-SV <br /> m 7 <br /> ❑State Owned -Describe Use <br /> ❑Cay_❑Village®Township of,SGO lel` <br /> III.Type:of Permit: (Check only one box on line A. Complete line B if applicable) <br /> New Syslem ❑ Replacement System ❑ Treatment Holding Tank Replacement Only ❑ Other Mudurication to Existing System <br /> 9. ❑ Permit Renewal ❑ Permit Res ision Lw Prev mus Permu Number and Date Issued <br /> ❑Change of ❑Pernw Tnniia w Nrw <br /> Before Espitaton <br /> Plumber Owner <br /> W.Tv a of PONTo System: Check all that a h) <br /> ,R Nun-Pressurized In-Ground ❑ Mound_>24 inof suitable sod ❑ Mound<211 in.of suitable soil ❑ AI-Grade <br /> ❑ Single Pass Sant Filter U <br /> Constructed A'ciland ❑ Pressurized In-Ground ❑ Holding Tank ❑Pear Filter ❑ Aerobic Treatment Unit <br /> ❑Recirculating Sand Filter ❑ <br /> Recirculating Ssnuhciic Media Filter ❑Leaching Chamber ❑Drip Line ❑Grasel-less Pi e <br /> V. D6ersal/Treatment Area Information: P ❑Other(explain, <br /> Design Flow(gpJI Design Sud Application RareigpJsl) Dispersal Arca Required Is1) Dispersal Area Proposed tsf) System Elevation <br /> 300 7 �t�3 ' r''Ip,ar /ow e <br /> `67.Tank Info Capacity in Total Number 9L 7 9d. 6 <br /> Gallons hlanufacturer Prefab Site Steel Fiber <br /> Gallons of Units Concrete Constructed Plastic <br /> New E.aubna Glass <br /> Tanks Tanks <br /> $epuc tar HuWmg Lok o� <br /> Aerub ie irraemcm L'nie <br /> a gd 1 .Sh0.H/ <br /> Dosing Chamber t <br /> %11. Responsibility Statement- I,the undersigned,assume responsibility for installation of the PO%s TS shown on the attached plans. <br /> Plumber's Name l Print l Plumber's Signature <br /> >� hll NIPRS Nwnber Business Phone Number <br /> RIG, /7c kir1,s _4� <br /> Plumber'i AJJress IS,reel,Gry,Stare.Zip Golden �/ '7�S— 86(v— evIs-7 <br /> 7 76 0 C/w 3S Ldgb Sfr>✓ C.tJ� ���93 <br /> 11.Court artment Use Ooh <br /> Approved ❑ Disapproved Sanitary Penna Fee Iincludes Groundwater Date Issued Issa.ng gent Signature 1 No Stamps <br /> Surcharge Feel /� (� I <br /> ❑Owner Given Reason for Denial `- r5v.Ol.J7� �i d i�'��,,,r'�, <br /> I\-Conditions of ApprovalLReasons for Disapproval <br /> � r <br /> B� 7 Zpp4 � <br /> Auech complete plans Ito eke County only 1 fur the ti stem on paper not Icss then 111.2%1$inches in sire CSV ~J <br /> VU <br /> SBD-6398 (R. 01/03) <br />