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' 9/24/2009 08:03 6088621730 PAGE 03 <br /> D Ecii « u <br /> rA, ). _ ....... <br /> commerce.wl.g•y l AUG 2nDaxp d Bu s Division County <br /> 201 W.Washingtor R'6„P.O.Box 7162 ti q i e <br /> i c s i [ Madison,W 537 @7-7162 Sent .j ..-' 4 I. In by Co.) <br /> r►7 bc Health MDC `• 1. • <br /> .�._....�•"• �� <br /> Sanitary 'ermit Application • State Transaction Number <br /> In accordance with s.Comm.83.21(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 difl'ciu„t than mailing address) <br /> submitted to the Department of Comtneroe, Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04��m1,�8tare, <br /> Z. Application Information--Please Print All Information <br /> Property Owner's Name f _ Parcel 4 <br /> Property Owner's Mailing Address Property Location <br /> j V CF •i P ,�{,s a Govt Lot <br /> City,State Zip Code Phone Number S - 1/4 't°�..3 / I <br /> � t '/., Section <br /> 0r6 e,e-1 c_.t 9 ° S357,- care ne) <br /> D.Type o ullding(Check all that apply) Lot i T N; R W <br /> .1P or 2 Family Dwelling-Number of Bedrooms ,3 Subdivision Name <br /> Block# <br /> ❑Public/commercial-.Describe Use - . <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Villa <br /> '111.Wnof 0V PI./A <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I?‹:-System System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal Q Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Data Issued <br /> Before Expiration Owner <br /> IV.'I' . . POWTS S stem/Cum.wont/Device: Cheek all that a.. <br /> - <br /> u' on-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable aoll ❑Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V,DisperaalfTrtatment Area Information: • . <br /> Design Clow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required Of) Dispersal Area Proposed(at) System p ovation r, 1 <br /> Li W) e �c 1 `a 5- I L 3Y c-;c2 i <br /> VI.Tank Info Capacity.in Total #of Manufacturer <br /> Gallons • Gallons Units • q a <br /> New Tacks Existing Tanks <br /> Septic ae-1la44ng-Task 4 0 <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> PI Name(Print Plumber, .'re / MP/ivfPRS Number Business Phone Number <br /> �e y , '.��ru :..- zZ-z3d (0,0gte7 Z—.37.1 <br /> Plumber's Add (Street,City,State,Zip Code) <br /> P , 0X 31-3 4e-' -�I "r 53, dZ... <br /> VIII.County/Department Use Only <br /> pproved ❑Disapproved Permit Fx Data Issued issuing •t Si: <br /> s o831J09 � <br /> ❑Owner Given Reason for Denial . �. 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> -r IA Su(C e. b to t(a ‘..k...., s -_. GLer f:1-1----- C 1. - S> 30 4 SkAevi--,.. <br /> • <br /> DB^ )(Dili iii f Attach to complete plena for the ryetam and submit t the County only on paper Nat lcie than a DI e,11 ictpm in.taee • <br /> CJrt l�iw' ( ` <br /> SDD-6398(R.01/07)Valid thru 01/09 •• • <br />