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k <br /> Oct. 12. 2009 1 : 34PM'• =-L .I. U -13_I • No. 1493 P. 1 <br /> i ��++co/mmerce.w v Safety ae B3 dings Division County <br /> +7 V SE E, 2 go12JO'ashin Ave-,P.O.Box 7162 -DQ M r: <br /> Medist 53707-7162 S 520bj )Q5Co.) <br /> Col+'drtment of Commerce <br /> ub..G flea h <br /> Saril - patjott State Transaction Number <br /> In accordance with s.Comm.83,2](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(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.s.IS.04(1)(m),Slats. <br /> I. Application Information-.PleasePrintAllInformation - jt5rh4 de Z. .X4 <br /> Pro ty Owner's Name Parcel# <br /> troyProperty Owner's Mailing Address Property Location <br /> D209'3 ti()_./SOX / Z ' 1U _ <br /> City Slate ' Zi Code .- Govt Lot A y late P Phone Number a-- <br /> `7 i'e v i e 5 3 ,T 1)7 (circ onc) <br /> II.Type of$ Iding(check all that apply) Let ti '- T N; R /( r W <br /> 1-1 or 2 Family Darelling-Number of Bedrooms 0 Subdivision Name <br /> Block N <br /> Q Public/Commercial-Describe Use _ <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of /1 <br /> IerTown of L.b4'A 4 C�r0't e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Pi New System Y ❑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 /> g ❑Permit Transfer to New <br /> Hcfore Expiration . Owner <br /> IV. .e of POWTS S stem/Com.onent/Device: Check all that a,.1 <br /> Of 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 /> _ <br /> "Design Fl w(gpd) Design Soil ApplicationRate(gpdsf) Dispersal Area R uirrd(si) Dispersal Area Pro po sed(st) System <br /> TO t �f f i J— ldi 9z.3 <br /> VI.Tank Ioo Capacity in <br /> Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks �Q3 h <br /> _ l a V Ti, i�. a <br /> Sept eorHoldingTank /ail d /6 t �G(rc e - <br /> Do,ing Chamber <br /> VII.Responsibility Statement-I,the undersigned,ash.u∎r responsibility for installation of the POWTS shown on the attached plans. <br /> Plum Name(Print) <br /> Pl MP/hhRS Number Business Phone Number <br /> .le eA_ Cro) i . Mg. r d 706 7 L.eyB- (7 v9.- 677 ( <br /> Plum 1s Address(Street,City,Slate,Zip ode) 'WI•. <br /> -13(.O ts ,1-0.3)r .'N. i r I ue t k,a. e_ �x 5 3 5-ta �' <br /> VIII.County/Department the Only — �� <br /> !I.Approved Permit Fee Date asued Issu _ ' , / <br /> PProved ❑Disapproved7f�i: <br /> ❑Gwncr Given Reason for Denial $ 1 9/2-t 09 ft,i, . Ya�f� g'5 <br /> IX.Conditions of Approval/Reasons for Disapproval rlltt,� <br /> Attach to complete plane for the system and submit to the County only on paper not leas than 8 rn x 11 Caches is sue <br /> Q,111(- 5x-74 <br /> SBD-6398(R.02109)Valid thr /I 1 <br />