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• <br /> -- few au■. ? <br /> -��t? NIiV .,,. ,r_A <br /> ve.,P.O.Box 7162 <br /> WI 53707 71st Sanitary Pest Number(to be meted,n by co.)�scons - . - 51-6)c9-// <br /> s, t ' .!w' !,.- r'° i on • Ste1ta ic1Nambar r- <br /> .,, i� �a �,S qy <br /> is a cord:nce with a_ Comm 83.21(2), Wis. Mm. Code. rab+onission of this.,farm to the appropriate <br /> governmental its required prior to obtairing a sanitary permit' Note-Application forms Air slate-owned Project Address cif d>Maw than mail*address) <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law.,s.15.04(1)(m)),Stets. 9 u .riot.�c� j �� <br /> I. Information—Please Print-AR Infatr afion Parcel# <br /> Property Owner's Name <br /> ii^-oev ) 1 ,r a y+eb N 4..n c./ E • 6 c. N rr ©b o to •-A t 3 - 9 coo - 1 <br /> Property Owner's Ma ding Address ley lino <br /> i o c c' w - Q lye tv,o v..d s 11..A . Govt Lot <br /> M,,Stare I Zip Code Phone Numbs- 3 w ti, w it„Section -2 I <br /> ( �) <br /> awe. MounJ3 i,v ; . . S3Sl7 �(v°aj 4132- 1(6 S� T Co N; R (o �W <br /> II.Type of Building(check all that apply) Lot# <br /> 3 Subdivision Name <br /> ®1 or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑Public/Commercial-Describe Use • - ❑ try of <br /> Cal Number ❑Village of <br /> ❑State Owned-Desenbe Use 13 Town of (51,,e. r-.o v'%c)•S <br /> III.Type of Permit: (Check only one box on rine A. Complete B if applicable) . <br /> ®' , ®New System m ❑Replacement System 0 ' Tank R Only ❑Other MotrifiCalker to Existing Systems(explain) <br /> Lit Pry Permit Number and Date lamed <br /> B. °Permit Renewal ❑Permit Revision ❑Change of ❑Penult Transfer to New <br /> Before Expiration Plumber Owner <br /> IV.Type of POWIS ((:heck all that apply) - <br /> CI Non•pied InGrooad ❑Presoaked la-Ground 0 At-Grade ®Mound >24 in.of suitable son 0 Mound<24 m.of imitable soil <br /> ° Holding Tank 0 Other Dispersal Component(explain). ❑Pretreatment Device(acpiain) <br /> V.Dispersal/Treatment Area Information: Area Regcared(sf) Dispersal Area Proposed(st) System Elevation <br /> De�i'iow(M) Design Son ll-a <br /> Li 5-0 O.L-0 '4 50 NSS - <br /> 1,11-?-5-1,11-?-5-VL Tank Info Capacity in Total I of Ivisoofacoater <br /> Gallons Gee Una ea-2i g 5 i <br /> New Tads - a en m A eg o E. <br /> Septic orH Taut `/o oo l to o b -_ /bon i C i C.> T <br /> Des*Clmtaber (y 0 O (poo I C r e .i X <br /> VIL Responsilety 9 I,the undersigned,assume responsibility for installation lithe POW'S strewn on the toadied piam. <br /> Phrmber's Name(*tin t) s twee MP/1p'1tS Number )lam Phone Number <br /> r ;��---'(' 74-.,,4 a a4,51 6 1.002.2C- 9125 <br /> Phimber's Address(Street,City,State,Zip Code) <br /> 1l1 e i '1 ' ∎d e. • t'. 0arne ve i w ; . S S-o 7 <br /> VIM County I - ,,, ,, Use Only <br /> Perm t Fee Date Isaac d l Agent, <br /> ❑Owner Given Reason for Denial _ <br /> IS.Conthtions of Approval/Reasons for Disapproval <br /> -A' ( <br /> Arin a a to er piece plans for the th <br /> and submit to e County orty an paper not less that S tax Ii inches in rise , , <br /> SBD-6398(R.01/07)Valid three 01/09 -r1 <br /> b - a1 c93- c,L g,- 1( �9 '- '-q\]:-.) <br />