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Jul, 28. 2009 2; 37P1M.11 [ () \\ii L o• No. 1036 P. 1 <br /> jj .-- <br /> +i`11 JUL 1 0 2009 1.,))ff� <br /> Iltcommerce.IWi.gd Safety at'd Builliings Division county <br /> . t . ., 201.\V.Y/4shi=Igton ve.,P.O.Box 7162 O�„ <br /> IS con in f I.:ir.c i`ki,d It i,')1vltadtson,WI 53707-7162 <br /> San' it <br /> V t1 <br /> 1 tik'it'..'iut, r�,;! Ir;iiifh S <br /> OopaMmerrt of Co meroe..:. ;1 :. <br /> Sanitary Permit Application State ransaetionNumber <br /> In accordance with a.Comm.83.21(2),Wis.Mm.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 different thanmailing address) <br /> submitted to,}hc Department of Commerce. Personal information you provide may be used for secondary <br /> .urposcs in accordance with the Privacy law,s.15,04(lxm),Stets. <br /> i...Application Information—Please Print All Information HWy <br /> Property Owner's Name • Parcel N J <br /> 1 s • sal, 5 An <br /> )} 1- n _ ow - . ^ '. :r•0 <br /> s , <br /> Property Owner's Mailing Address Property Location <br /> 5a'4 }Jtt„i Sig Govt.Lot <br /> City,State Zip Code Phone Number , , <br /> N6' /r, 5 W /A, Section__/$ <br /> 614t4).110/1,] WI 535$1 )0T Z/2- (°i1 ober nc) <br /> T 0 N; R it rW <br /> IL Type of Building(check all that apply) t1 Lot N <br /> IX 1 or 2 Family Dwelling—Number of Bedrooms y j Subdivision Name <br /> Black N <br /> U Public/commercial—Describe Use ❑City of `• <br /> n -1 Owned--Describe Use <br /> 'r CSM Number 0 Village of, • <br /> A Town of, ,Olt 114/AeldrA <br /> I i I.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) —... .. <br /> 1111 0.New System 0 Replacement System 0 TteatmentJlioldfngTsnk Replacement Only 0 Other Modification to Existing System(explain) <br /> ill <br /> 0 Permit Renewal El Permit Revision 0 of Plumber Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of P01VTS System/Component/Device; (Check all that apply) <br /> N Non-Pressurized in-Ground 0 Pressurized In-Ground • 0 At-Grade 0 Mound>24 in.ofsuitablc soil a Mound<24 in.of suitable soil <br /> 1] I folding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dis)ersal/Trcatment Area Information: _ — <br /> Design Plow(gpd) Design Soil Application Rate(gpdsi) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> r.. I . H 15o7D /500 se, 5/14' pfin _..' <br /> VI.Tank Info w� Capacity in Total N of Manufacturer <br /> Gallons Gallons Units t <br /> New Tanks CxlstinaTsnke Y1 g H u u x . n <br /> op n <br /> �U in II w r-7 a. <br /> Septic nr holding Tank I r_Oo ,1 WO . ......1 �Af MO ray COHtsp A <br /> Doting Chamber �0 wee <br /> VII,Ices onsibill Statement-I,the undersigned,assume responsibillt/for histallation of the POWTS;horn on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature htt/MPRS Number Business Phone Number <br /> .Spa. . Lavr,k :hit. _ —7.- ZZ357Z 920.98$-75'67 __. <br /> A <br /> Plumber's A.dress(Street,City,State,Zip Code) <br /> P.O. box 503 L4cr /Y !k k 551 .. _ <br /> V I.County/Department Use Onl ,'Approved U Disapproved Permit Fee <br /> $ Date Issued Issuin: - Sign . <br /> _ 0 Owner Given Reason for Dental 4/ 00 7/ve 3 0' ■ <br /> IX Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system end Submit to the County only on piper not Ins Than a in s I I inches in sloe <br /> D E--5,l'AT C-k`k— 50 .)(5(p (d for. h-C 4A./ die0-45ei '7,-/(-c77 acg <br /> sup-6398(R.01/07)Valid thtu 01/09 7` 2. z• ? e 44/ 6:1--%W-- -1 .L( <br />