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. • ,Oct. 29, 2009 10:37AM l I IC Q W ut- No. 1593 P. 2 <br /> 1 commer• _�� goV p ,yySttf=" ;Buildings Division Count ' <br /> lS■ CO t Q U�y % I. .n Ave.,P.Q.Box 7162 _Do ne_ <br /> V ti` �Cit M: WI 53707•-7162 San t. ' ,) <br /> _� Department of v . arcs <br /> S� a on State Transaction Number <br /> In accordance with s.Comma, lt$M'• a�lu i� I •L !d i <br /> unit is required prior to obtaining a sanitary permit. �Note:�Application forms for sate-owned POWTS are Project Address(if ditlëreat than mailing addrei) <br /> submitted to the Department of Commerce. Persona] information you provide may be used for secondary <br /> _err oses in accordance with theme Law.s.15.04(1)(L4 Slats. <br /> Application Information-•Please Print All Information "" <br /> I. <br /> Property Owner's Name e • /O SS <br /> Parcel d <br /> Property Owner's Mailing Address ` Pro gLocation —6 _... <br /> 3I(o rhernsa,,. 0 '1ve Govt,Lot <br /> City,State Zip Code Phone Number <br /> N/6 v., w ''4, Section 2 <br /> SLA-ki r ✓'txl'rtt Loa Z_3Sgo (circle one) <br /> II,Type of Building(cheek all that apply) �{ • Lot T N; R I b E or W <br /> J or 2 Family Dwelling-Number of Bedroom q if SubdivisionT7ame <br /> —/ Block# 6toh✓ke's ILKo/ <br /> ❑Public/Commercial-Describe Use <br /> �'+ ❑City of <br /> ❑State Owned-Describe Use CSM Number II Village of <br /> _ V Town of fu eke <br /> III.T`yrpiiiiPeltaeck only one box on line A. Complete lint B if applicable) <br /> ®New S ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> D 0 Permit Renews] List Previous Permit Number and Date Issued M <br /> Before Expiration �er Ne'v <br /> Owner <br /> IV,Type of POWTS Sy stem/Corn poneniJDcvice: (Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-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 Rate(gpdsf) Dispersal Arca Required(s) Dispersal Area Proposed(s stem Elevation , <br /> D 0 ,Y /S'a d _ /,-o o , a 7,6 17, 3 <br /> VI,Tank Info Capacity in Total tl of Manufacturer <br /> Gallons Gallons Units f d T o <br /> Nowow Tanks Ilinks <br /> �� <br /> a.t.) in" � W(. E. <br /> •iiHolding Tank — � -- <br /> Chamfer 1 za.0 62, +,G i /7/ea�'e p <br /> Gm 65-u ( /pen I,r <br /> VII.Responsibility Statement-I,the undersigned,assume rues..nattily for lnstallatloo dare POWTS shown on the attached •laos. <br /> Plumber's Name(Print) Plumber MP/MPItS Number Business Phone Number <br /> 51-e pie A to r'as•4,,, - 1is-/i,,, - A • 2 92 t G thy v I <br /> Plumber's Address(Steel,City,State,Zip ode) r - <br /> "l,3 l a l --Doi r I.t, 3 r 1 t)C :)tk lV e_ f e-J.r s . off- ct <br /> VIII.Couaty/Departmt eat Use Only -- <br /> Approved ❑Disapproved <br /> Permit Pee Date sss7ue Issuing ent Signa y <br /> _ ❑Owner Given Reason for Denial $3 G• lb y�{� y,. <br /> IX,Conditions of Approval/Reasons for Disapproval ` <br /> LI~`°� Ag . A�t(SIS .t 1 f -WI.(afe f S i C..rs:&-3-:4 -qt_c_A-:-.6--= <br /> Szi-CL A-Laie DI k_ f <br /> AB''" i 7 F� Attach to complete p ns or 'e opMtMP su'mil tothe County only on paper nor less than8v4x11India In the <br /> K—� 34iS'g/ <br /> SBD-6398(It.02/09)Valid thru 02/11 <br />