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Jul. 6. 2009 8: 25AM ir,. _ .'. Y0. U876 f
<br /> Safety County
<br /> comtnercei I'(g)V , afety ,ills prldiugs Division Coln t
<br /> ■ i, JUN 2 62(12 \VnS)I 't Ave.,P.O.Box 7162 �,y,,, ' —
<br /> i sco n in Midi alt,-r 53707-7162 Sal' of in 1 in by('n.)
<br /> Dopartfnont of Cnnnngeo
<br /> F'+.IfiIIG ?.r 41 :60-(71-2:-.
<br /> ,rice'` °--- _. ..,..._—_...
<br /> h ." ( Slate Transaction Number
<br /> Saux>to�-�t1��r i�t aA,PP��.4�lti�n P°141.
<br /> � 5 4 if I7 8q 7
<br /> In accordance with s.Comm.Ili 21(2),Wis.Adm.('tile,submission of this funs to the apprupriate guvermmental
<br /> unit is required prix, to obtaining a Sanitary permit. Note: Application forms for state-owned POW IS are Project Address(it-different than nlart111F,address)
<br /> submitted to the Department of Commerce. Personal information you provide may be 115cd for secondary
<br /> _prorposes in accordance with the Privacy Law,s. 15.04(1 ant),Slats.
<br /> I. Application Information-Please Print All inforinalion
<br /> P,opeity Owner's Name ) -- P.ucel11
<br /> 7'6./ i 1 ,,c-c./-/C t.C-C4 AS LS E cCAI �/!'J/7"// 0 %v-.// .// '_ (7
<br /> ...-- ---• Property Location
<br /> _ ._._..--.-
<br /> 3 roperty Owner's Mulling Address r P rty
<br /> 42y17 e, :A.,/A- G/./ .fir / CAn)J� Govt.Lot
<br /> City,State Zip Code Plante Number 5-i.ts1 /,. Sr- %., Section 1/
<br /> YJ,QU/./s A.)) (v1 5---17(7.3 ._ (circle one)
<br /> — T N; R ,", F oraV-
<br /> Iyi.Type of nuilding(check all that apply) / l-ot!!
<br /> If 1 Or Fancily Dwelling-Number of'Bedrnnnis Y Subdivision Name
<br /> block!!
<br /> UPublic/Commercial Describe Use
<br /> --- U City of
<br /> ❑Slate Owned-Describe Use (:Shl Number Village of
<br /> ` 1/
<br /> ill.Type of Permil: (('heck only one box on line A. Complete line)3 if applicable)
<br /> A. 'NcwSystem L.I Replacement System ❑TreatinentliloldingTank Replacement Only n Other ivinditication to r'xisting System(explain)
<br /> I. U Change c+ List Previous Permit Number and Date Issued
<br /> ❑Permit Renewal n Permit Revision 6 f Plumber ❑Permit Transfer to New
<br /> Define Expiration Owner --�_..._......
<br /> IV.Type of FONTS System/CumpnnenUI)evice: ((peck all that apply) .
<br /> U Non-Pressurized In-Gwumd ❑Ptessw iced In-Ground n At-tirade ''Mound_24 in.of suitable soil U Mound<24 in.of suitable soil •
<br /> ❑Holding Tank n Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gild) Design Soil Application Rute(gpdsl) Dispersal Area Requited(sl) Dispersal Area Proposed(st) System Elevation
<br /> 1
<br /> C.4:717 /. Lau lri cacP /v , g-
<br /> VI.Tank Info Capacity in Total !!of Manufacturer
<br /> Gallons (iullnns Units E o'
<br /> New'ranks '--.._. 6.isiing Tanks ' p; z°z y ,K�3 5
<br /> X:U in U rn w 3 a.
<br /> Srptic+srltbhtinl'.Tank �..? a V ..'V / ��r/4.4.4,a..).2)-- st
<br /> Dosing Chamber 7 fo -spa / ., 'V-
<br /> VII.Responsibility Statement-I,the undetslgnetl,asannte rerponslhitity for installation of the POW'I;Sahow n 11,c aitached plans.
<br /> Plumber's Name(Print) u er's Signan c„,.. A1t`r�h1PRS umber Business Plume Number
<br /> Moak.Z° .et,1,k�a-u-v • - --- --a= al al.3 (600 8'7 3-s obi.
<br /> �r
<br /> Plumber's Address(Street,City,State,7.ip('ode)
<br /> 6113- .`:.;t0.-4-C. l-R„ 1,3S, sip( I ,fvn, ul( 535
<br /> - Viii,Conn ty/l)eparlruent Use Only...
<br /> ` . ppruved ❑Disapproved
<br /> Permit Pre Dale Issued Tssuit !)pen igmia ore$e....„,„ C, Ne/t4Nr.
<br /> n Owner(Jive's Reason for Denial M.,45, "' r7!3—0
<br /> IX.Conditions of Approval/Reasons fur Disapproval
<br /> --> S€ P°W 73 O'NFR s /14140(16- f I /9G M (7 /AY.
<br /> Attach to(complete plum for the ayelem an/J,subnlil Cu the Cuuuly oily o■paper not Iran(trail 8 in x I I inches In 8171:
<br /> De- 0-x.0 to CA)4z, w 5039-4 v1yJ
<br /> 1(A Re
<br /> SI3U-6398(It,02109)Valid then 02111 t$C 6.'?erry i.
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