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f RECE Safely and Buildings Division Cotmty <br /> 201 W.Washington Ave.,P.O.Box 71G2 <br /> � Mattison,WI 5;1707-71G2 �� -1 A s s p K AUG 2 41015 Sanitary Permit Number Ito he tilled in by Co.)�1 <br /> t ^i Public Health MDC /�y�� <br /> nvironmental Hekilt_kt )3 Q 1 S lit J� <br /> anitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2).Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address Of 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 Privacy Law.s. I5.04(1)(m),Slats. <br /> I. Application information Please Print All Information - ,`10 ,' ve,-1 i ey Ra w i <br /> Property Owner's Name Parcel tt <br /> :i S C,O+fi L.e e . . V <br /> ''0 70 7 '- '7 A -1001 - •7 <br /> Property Owner's Mailing Address Property Location <br /> ro <br /> Govt.Lot <br /> City,State <br /> Zip Code Phone Number <br /> cla‘�c 1C E�� Nw '/+, S.✓ '/., Section '7 <br /> ' e.J ,SC r S-gS-7.7� `(.t�1C� 7 t J� -v�- ,-i (circle one) <br /> H.Type of Building(check all that apply) Lot q T 7 N; R '7 (�neiV <br /> I or 2 Family Dwelling-Number of Bedrooms_________ ! Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> -- ❑City of <br /> ❑Slate Owned Describe Use` CSM Number ❑Village of <br /> Town of S;floss ete;"S <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 Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> 6 ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV,Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑Pressurized In-Ground ❑Al-Grade ❑Mound.24 in,of suitable soil .®Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area information: "" <br /> Design Flow(gpd) Design Soil Application Rute(gpdsfl Dispersal Ar equired(id) Dispersal Aro Pro osed(sl) System Elevation <br /> Vl,Tank Info Capacity in Total l 1)of Ma uh lecturer <br /> Gallons Gallons Units <br /> Non tanks E.isting Tanks <br /> Septic or Holding Tank <br /> rn w c7 a <br /> ooc i3 vv ) On1V..t,, <br /> 1 I 3v:� <br /> Dosing('lumber 7, _ p...11 <br /> ;K <br /> 7>0 l 0A1w..�rtlr x <br /> Vil.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature MP/MPRS Number Business Phone Number <br /> 5-U1^^ 140 ,,,,,.., 14c,„,.,_ a a3sN 7 (Cots)5'4 7 - .735/0 <br /> Plumber's Address(Street.City.Slate.Zip Code) <br /> to 7 Y G, Cos. A 4-y Z ucJ 00 r,-5:..er-.a. ) (30:n+ ) w 1 Se— <br /> VI I.County/Department Use Only �3�G' S <br /> Approved ❑Disapproval Permit Trench S 475 Dale issued issuing Agent Signature <br /> ATG.Mound,HT S 525.00 <br /> ❑Owner Given Reason for Denial Reennnecl Fee$200. <br /> �2 � q -/5 m- , <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to camplru•plans for Ihr system and submit to the County only on paper not less than R Ir2.11 Inches to Alm <br /> F2r044-+' 74{rrc�( 0-7O-7 o73 £BSI -`1 <br />