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, Jul. 7. 2004 11 : 03RM---'•- ' _�--, i No. 0892 P. 1 qi)) FE 4 E II Wi E -v .t#k <br /> ,z <br /> •� ' JUN 23 2005 i ' <br /> _ <br /> _ <br /> commorc F.w. ov Sct iii- , ildings Division • County r <br /> . . .. . 20.1 1V.Wa ' gt In Ave..P.O.Box 7162 ---i <br /> ti SCO i UI H Ill; vil)(Itifad son, . 1 53707-7162 Suni .P i(N r e i Co.} <br /> OopartVVmont o C ran — tVIFL Cl i'r? r#4+ (a alEh __ m , S <br /> Sanitary Permit Application StateliansuetionNu m bcr • <br /> In accordance with a,Comm.83.21(2),Wis.Adrn Code.submission of this form to the appropriate governmental • - <br /> unit is required prior to obtaining u sanitary permit. Note: Application forms for slate-owned POWTS urn P rojectAddress(ifdifferenttitanmailingaddress)— <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.15.04(lxm),SEats. - <br /> I. Application'information-PleasePrint All Information ��r .� `�.. <br /> Property Owner's Name , Parcel F <br /> 1 4 P'.29.s t ti'4.e, o 2.•-oq a s - 6 i i - Ess'ls-c, <br /> Property Owner's Mailin Address ProperlyLocatl00 <br /> (b. % 5Ahl 12,o , Govt.Lot <br /> City.State zip Cori: Phone Number matt y,, nK Section - 1 • <br /> Lo a ‘..,-.a'=, 5 55� e_ _ 5-/-5---01186 ircl Ile) <br /> I .._ _ T � �N; Rr1Y <br /> 11.Type of Building(check all that apply) t•otil - <br /> • <br /> -Eror 2 Family Dwelling•-Number Of 3. Subdivision Name 3 <br /> h ock II <br /> ^ <br /> ❑Public/Commercial-Describe Use ❑City of • <br /> ❑State Owned-Describe Use GSM Number ❑Village of i _..__. - • <br /> bwn of ��A.a <br /> III.Typo of Permit; (Check only one box on line A. Complete line It If applicable) <br /> A. ,mr New System ❑Replacement System ❑Treatment/lfaldingTank Replacement Only ❑Other Modification to Existing System(explain) <br /> ""' — List Previous Permit Number and Date Issued <br /> J. ❑Permit Renewal ❑Permit Revision 17 Change of Plumber ❑Permit Transfer to New . <br /> Beforo Expiration Owner <br /> 1V.Type ofPOWTS System/Contponent/Devicct (Cheek all that apply),,, -M, ... <br /> { Non-PressudtedAt•Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 In,ofanitahie soil ❑Mound<24 in,of suitable soil <br /> o Holding Tank 0 Other Dispersal Component(explain),,., , 0 Pretreatment Device(explain)_ „__ <br /> V.Dispersal/Treatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) • Dispersal Area Required(st) Dispersal Area Proposed(si) System Elevation / <br /> •/�--o y / /as // z.9 i 1 4g11o' cub- Sr1-3 <br /> _ o <br /> VI.Tank Info Capacity In Total #of Manufacturer a b Gallons Callons Units }}} v <br /> ,� <br /> New'ranks Miming Tanks •g. p <br /> V te co w0 a <br /> _ <br /> Spriaartei lk h, g.-AO If , )00a ? i1i . <br /> � — <br /> Dosing Chamber ' <br /> VII,Responsibility Statement-7,the undersigned,assume responsibility for Installation of the POINTS shown on the attached pions. ^^ <br /> Plumber's Name(Print) I' mobs's Signal lift; � X13/MPRSNumber nosiness Ph ne Number <br /> �/f <br /> Plum is Address(Street,Ciiy,State,Zip code) ' <br /> VIII.County/Department Use Only - <br /> Pcrmit Fee f>atc7ssue,l lssuin en1 SignattueG <br /> 0Appmved ❑Disapproved S 1� �, /��Q�, <br /> ❑Owner Given Reason for Denial T c �a <br /> IX.Condition;of Approval/Reasons fir Disapproval v. <br /> Attach to complete peens for the system and submit to the County only on paper not less than 8 Ut x I t inches in size <br /> b - Otey'1 C K— 5oa.32✓ • <br /> SBD•6398(R.01/07)Valid thru 01/09 <br />