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Oct. 15. 2009 12; 09PM,: —T- --I ' p ti No, 1512 P. 1 <br /> 1 • ' commerce. rik. ; a 1 1 dings Division County t;201 W.Wash : 101•NT.,P.O.Box 7162 Oa kW <br /> $CO fl adi ' U 1 53707-7162 Sanit _ ' ' N r to , d I. o.) <br /> i3aparlment of Co =�- QC 20 <br /> Ali►_• r <br /> Sani r r' # r l n tic, State Transaction Number <br /> In accordance with s.Comm.8311 ),Wis. •i4vc10fr1 . #ip1• form to a appropriate governmental <br /> unit is required prior to obtaining : „∎• r• i• 'o pp ma ion orms -or state-owned POWTS are Project Address(if 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,r.15.04(1Xm),Stets. ' <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# - <br /> 1� w,� Di A/ usery er3 $� 312 -000—000-- U L . <br /> Property Owner's Mailing Address Property Location <br /> 7. 3 .0q G '/ 1—r ( Govt.Lot <br /> City,State /, ' � Zip Code Phone Number yy /WV Y, Section 7 <br /> t0414-0)•1 �-1^ ( (circle one) <br /> I apply) T N. R BorW <br /> Type of Building(check all that e l Lot# <br /> El or 2 Family Dwelling—Number of Bedrooms I Subdivision Name <br /> Block# ALI'I[trei fV (hQ <br /> ❑Public/Commercial—Describe Use --1 <br /> ❑City of <br /> CSM Number ❑Village of <br /> D State Owned—Describe Use _ n I n <br /> 2 Town of tsr e r fry fl~t'P I U' <br /> ITT.Type of Permit: (Check only one box on Hue A, Complete line B if applicable) <br /> A. <br /> ®New System ❑Replacement System ❑Treatment/HoldingTank Replacement Only ❑Other Modification to Existing System(explain) <br /> B Change ❑Permit Transfer to New List Previous Permit Number and Dale Issued <br /> ❑Permit Renewal ❑Permit Revision ❑Chan a of Plumber <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> IR Non-Pressurized In-Ground CI 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.l)is■ . reatment Area Information: —,.,rmann.... <br /> • ign F.. (g. Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sfj nS N.m-ElevoliQn '` <br /> 7 5-0 1 /C5'75 /` 7 5 ( ceP eQra ,-a <br /> VI.T,nlr nfo Capacity in Total #of Manufacturer __--.- <br /> Gallons Gallons Units I o c <br /> New Teaks Existing Tanks 42 1 p - <br /> ad u rn co is.t 7 P, <br /> Septic or Holding Tank r, a <br /> Dosing Chamber <br /> / l d Jrd 6 P d I—e eV <br /> p O U Roo, / /�1e0 P <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature hofP/MPRS Number Business Phone Number <br /> jpnneYh 44e II-r 41421 -0/4 ►- - AP-y/-7e," 4,d8- ev9- dr7-7 1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 13(0 l —DO)r (.t r i Ve h4.nle_ (eJ S C-aa <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing /tit Signature -,/ . <br /> ❑Owner Given Reason for Denial Sada'!— to �"-I �A <br /> Ix.Conditions of ApprovalUReasons for Disapproval '// `�� <br /> Attach to complete plans for the oaken sad submit to the County only on paper not less then 8 In x it inches In size <br /> 6 - 2R D- <br /> c tY - 53aao <br /> SDD-6398(R.02/09)Valid thru 02/11 <br />