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J u 1. 15. 2009 2:40PM-,\ .., \..! . ".,...::: hT .,.. .,.., ..- - ,,, - .•., No. 0944P. 1 /
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<br /> .aommerce.wi ,. .vi.
<br /> 22 ' 4 _Pved ings 1 Division F,'i;.4
<br /> Ad W_.Was' Ave4.0.Bx
<br /> scons Maw 1i 5 /07162_ n , A ir
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<br /> DePeitme" "' -i, .'.4..., .. •;: i I .:Q'A-;,e.-' 3 -IF al .
<br /> . s a la, . .. eimite, i .., ,,,i,,J-„:ic: i... ,!k , iv.t DC; S, ,Transaction Number . .
<br /> . . CO -151.ni.r,41.0:;r3) ..; f. :11;i ' ,,,, /„/A, c. (.1--- q- 37O •
<br /> In accordance with s. Comm. 53.21(2), Wis. Adm. Code. submission of this form to the aPproPiiiiie-. 14-vM.
<br /> governmental unit Is required prior to obtaining a sanitary permit. Note:Application Terms for state-owned Project Address Of different than malting address) •
<br /> 'POWTS are submitted to the Department of Commerce. Personal information you provide may be used for
<br /> second. ..,■1,...-(n accordance with the Priva Law s.15.1 h.. Stets. -
<br /> I. Application Information 7 Please Print AU Information ' ip r • ...,VV
<br /> Properly Owner's Name Parcel i . . .
<br /> Ge^e 6 ee.lk fri-Ar's 406-02 2— gtogo-6
<br /> Property Owner's Ma icing Address • . Property Location
<br /> it°2. -S-', cl- J-f, .
<br /> Govt.Lot .
<br /> City,State Zip Code . ' Phone Number NW.41,1,14,Section
<br /> Alt, P-OgE g i. kv<1 .. • • _535-72. .
<br /> (circle one)
<br /> — T Co N; R Cs Mar W
<br /> II.Type of Building Ohara all that apply) Lot d .
<br /> • Subdivision Name
<br /> Ii or 2 Family Dwelint-Number of Bedrooms Li •
<br /> 'Block/
<br /> 0 Public/Commerclal-Describe Use
<br /> • 0 City of
<br /> CSM Number . 0 Village of --0 State Owned-Describe Use il
<br /> lif Tovm of Clue
<br /> . .
<br /> ....... . . . _.
<br /> III_Type of Permit: (Cheek only one box on line A. Complete line B if applicable)
<br /> A. MI New System ' 0 Replacement System 0 Treatment/H(Ming Tank Replacement Only 0 Other Modification tO Existing System(explain)
<br /> B. 0 Ronk Renewal El Permit Revision 0 Change of 0 permit mower to New List Previous Permit Number and DOC ISSued '
<br /> Bent Expiration Plumber Owner
<br /> . ------- 1
<br /> IV. J,• of POWTS •'stem/Com,1 nent/Devices Cheek all that a, ,v
<br /> 0 Non-Pressurlsed In-Ciround Cl Pressurized In-GrOUnd 0 At-Guide :El Mound Z 24 lit.of Suitable sou 13 mound<24 b.of suitable soil
<br /> 0 Holding Tank 0 Other Dispersal Component(explain) . 0 Pretreatment Device(explain) .
<br /> V.Dispersalfrreattnent Area Information:
<br /> Design Plow(gpd) Design Soil Application Rate(gpdsf) ' Dispersal Area Required(if) Dispersal Area Proposed(el) System Elevation
<br /> —laza— 0. (es 6 co (Oct) JO .50
<br /> VI.Tank Info Capacity in . ' Total I of Manufacturer #1 •
<br /> Cations Gallons Units--1
<br /> New Tanks Existing Tanks li il A. 14
<br /> Septic argeldite Tank ....— /
<br /> ..00 . ( 0 Al yiAzxl-cl-1
<br /> . •0
<br /> Dosina Mamba -- •
<br /> • .. '2 b .. 1 A
<br /> VII.Responsibility Statement-I,the us.- ,._,...■ assume responSib I for installation of the POWTS shown on the attached -i..
<br /> Plumber's Name(Palo t) Plumber's Stine tare ... _...,. _ MPIMPRS Number Bushress Phone Number
<br /> SOh n T /-1(29.0..--, c2,0‘ /....__/*-'7 a?3 571_7 _ (04,i) 962 3,Ao
<br /> Plumber's Address(Street•City,State,Zip Code) /
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<br /> VW.Colin •/D-,, ,,,emt Use Oni
<br /> " (Approved 13 Disapproved • Permit Fee Signature
<br /> issued - Issuing • S nature
<br /> ..10'11-t
<br /> 0 Owner Given Reason for Denial 1 808`.— 7-,-0? -e-,0 -- ; a--V-L-1
<br /> ...
<br /> IX.Conditions of ApprovaUReasons for Disapproval
<br /> Atbach to complete*us far thespian and saran to the County only on paper not Ins than 8 in x 11 Inches In sire •
<br /> SIIMINIWirotagrarattirweeme D i3,,,..T-1-7 48 ah K-575 il 75-
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