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Jul, 28. 2009 9:41AM . ... . _. _..._.•. No. 1024 P. 1 _ ir iii,' (; k_ll._.V - !1 .- commerce. -•. ' ..ft ety a �tildings Division County •�+ , '% , 201 W.Was in Ave.,P.O.Box 7162 //►� rE e 'scan h �� 2 4 200( fadi:•1 r 1 53707-7162 Sanitary ' 1 ' yCa) Department of Co 1 n. c i p n 4 ` San tai 'l� ,Mt- p 'ati �� State'I ran saOuunNarnber In accordance with s.Comm.$3.21 2),Wis, i ikryfFn1E61h(toli tklglli�is form f� the appropriate governmental unit is required prior to obtaining• , ) i hut. Note: Application Corms for state-owned POW'I.S are Project Address(if different than mailing address)• submitted to the Department of Commerce. Personal information you provide may be used for secondary imposes in accordance with the Privacy Law,s.ISti1.1521,Stars. I. Application Information-Please Print All i n f o r m a t i o n T :+'U 1 1-at n e Pro pr er's Name Parcel N Prouty tt)w(ter's Mailing Address c1 Property Location 6� Kay; r Kc4 �4!i�t....1 tr�if t 6-3 N� J�`o o "if' Govt,Lot ... // City, to ,c--.. Zip Code Phone Number ftJ1,v 'A ki^ 'A, Section !1_ ECU _ f-r'6t t t l'e (,(, _ - 3 rO (circle one) T (I Ni R 1t_ Coral II.Type of Building(cheek all that apply) Lot II Aker 2 Family Dwelling-Number of Bedrooms _ / Subdivision Name M t� Mock 4 li,f o P Go a 4 Oz ec, £S. n Public/Commercial Public/Comercial Describe Use_ r U City of 1 CSM Number ❑Village of U sue Owned—acseribc on — lit'[own of 0 r 100 I — w III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑Replacement System ❑Treamttnt/Holding'1'enk Replacement Only U Other Modification to Existing System(explain) It. ❑Permit Renewal U Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and rate Issued Before Expiration Owner IV.Type of l'O11''I'S System/f:ompuncnl/DCsiIce: (Check all that_n rly) ,. n Non-Pressurized In•Grotmd ❑Pressurized In-Ground ❑At-Grade^ Mound>24 in.ofsuitahle soil U Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) U Pretreatment Device(explain) _— Elevation Dispersal/Treatment Area In ormation: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(s[) System__— • • /1 4 U -,/.1.0--.__.. �- 6 0 o G d .) .. /01.5 i Vi.Tank Info capacity n Total t1 of Manufacturer Gallons (tattoos tlnits a b New Tanks Existing Talks 'y a C Ti 1 w u in u rn r2 0 FL," cptj 2 Hutding ,1, / ,,rra�n� oe Do ng Chmnber GL so .—6-57) I /)1 E'44:e IX VII.Responsibility Statement-1,the undersigned,assuru. es o dlbilily . Hallal . of(h )V478 shown on the attached plans. Plumber's Name(Print) Plumber's'gnature MP/MFRS Number Business Phone Number S 1 'ie in t. Cros b ✓ a./.;1 7o°q 668- ev9 6)71 ? Plumber's Address(Street,City,State,Zip Code) - 7340 l L�ch r (•'' .) r i tai 1 k- C.Al r L. - 5 :3 S o? '' ViiI.County/Department Use Only ,_■ _ „ �Approvcd n Disapproved Permit Fee t Date sued Issisin• ,gent Si. a, ., YYYYYY $ i Ge ❑Owner Given Reason for Denial Ii _..ar _ .-.< . 1X,Conditions of Approval/Reasons for Disapproval x Attach to complete plans for the system and submit to the County-only wi paper nor lass than g 1/2 x 11 inches to slit De 2521( NI( 51055 SBD-6398(R.02/09)Valid thou 02111 •