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., —.i r�* Safety and Buildings Division 't- <br /> f, <br /> t I 201 W.Washington Ave.,P.O.Box 7182 Saaiday PerrnitNualor(to bo in by Co,) <br /> t I;9:)'.. Madison,WI 63707-7182 <br /> 12015--ciO� <br /> Sanitary Permit Application Stets Dammam Number <br /> In accordance with SPS 383.21(2),Wis.Mm.Code,submission of ibis form to the appropriate governmental unit <br /> le required prior to obtaining a sanitary penult. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Depadraent of Batty and Professional Service. Personal information you provide may be used for secondary <br /> purposes in eeoordance with the Privacy Law,x.13.04(1*,State-. `f7a'( /, „7. CQ♦ E <br /> L Application Information-Please Print All Information / WI7 v� <br /> Property Owner's Name Parcel# <br /> k 1 iel< E UaxoNi 0 71(- 04,42.- €(8to .0 <br /> ProperttyOwner's Mailing Property Location <br /> / - <br /> r l es- R t 0 - <br /> Govt.Lot <br /> Cfty,State Zip Code Phone Number AK %, N101 S4,Section • <br /> V,w .DYNE WI s-''Q7q r (circle one) <br /> II.Type of Building(meek all that apply) Lot# / T ( ,N; R i'( B er W�- <br /> IOI•or2Pami lyDwelling-NumberofBedrooms - . . SubdivisionNante <br /> Block# <br /> I7 Public/Commercial-Describe Use ©City of <br /> ❑State Owned--Describe Use CM Number ❑Village oP <br /> 6 77 ),Town of o1 I Pirove <br /> M.Type of Permits (Check only one box on line A. Complete line B if applicable) ��,�,� <br /> A' ❑New System 0 Replacement System ©Treatment/Ho �LI''f <br /> kthng Tenk Replecoareett Only �Otirem>ttedl[iaaUen to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Lim Previous Pena Number and Date Issued <br /> _Before Expiration Owner ( �_o/q/ et-740-007 <br /> "HIV..Type of POWT$ietem/Componeni/Devicel (Check all that apply) PPM' tra gob T v. <br /> J�.Non-Prosaudzed]n•Orormd ❑Pressurized In-Ground ❑At-Grade ❑Mound?24 fn.of suitable soil 0 Mound<24 in.of sultab coil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersaVPreatmentArea InformationI <br /> Design Plow(gpd) . Design Soil Application Rate(gprbf). Dispersal Area Required OD Disposal Area Proposed(at) I System Elevation <br /> 'T5e, +ccsottrtf,-. _ ( S2 ace ri; <br /> VI.Tank Info Capacity in Total *of Manufacturer <br /> Gallons Gallons Units ii 11 1 M I <br /> NawTa,k1 Existing <br /> ngTcmks <br /> Septtoor . `Took 1000 . !'OttiD ( $? ' ' _4Pfrria A <br /> nooks Chamber ' <br /> VII.Reeponaibillty Statement-I,the undersigned,assume respondb ty for installation of the POWTS shown on the attached plans. <br /> PI Name Of* Plum M7P 7umber Business Ph 1°Number e ei4e / ' j ��,2-7c <br /> d <br /> ?limber's <br /> Ad (Strict City,Stab,Zip Code) <br /> ce4 t /4 �;,'N Lie // 2C321..0i4e 41 7Aiev ss�,/ i 6-?0y/ <br /> / <br /> Conn /Department Use OAP <br /> Approved ❑Disapproved S p <br /> Permit Pee Date Issued Ism A go <br /> Ar <br /> 0 Owner Given Reason ferDenial "! ( 1S fS C <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 4/', eP Raga"ccAre-To," -r ref- <br /> r6 7 fr/f rc,-\ Rag([-D ulrE orty I'�j 6)et r A - rt ,040,3;; <br /> Attach to eomplatoplau tar the system and submit to Om County only an papa not loss than II ui a 111aohee to du <br /> SBD-6398(R.11/11) Mk eilecic Pte' r A-#� `; 1 <br /> C( 7? of /ti 400 fry/ .T>+2t n,I, e Z, <br />