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Jun, 22. 2009 2:24PMiliii.); : . ..,:=, • '''t,:.: -.,.. . No. 0775 P. 1
<br /> •" • County s
<br /> - commerca.w1;gov
<br /> it
<br /> . .. ' 1 201.1‘,/, NyoshingtO){4 c.,P.O.Box 7162
<br /> ' l'i ' iddisiiir'km 3707-7162
<br /> isconsin .. i ,- - s- 1 1.4. -.
<br /> ... nbo: :' .by Cul
<br /> Departmorit of Commerce, . • ., :, .,.... .
<br /> . 1
<br /> 10 State"fnmsaction Number
<br /> San itll ry,Pseinii k.. ' t) • .
<br /> In accordance with s,Comm.83.21(2);Wisr AilaiggiAtagai A Mil. lisrn-to•il appropriate governmental
<br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS ale Project Address(if ditfei;iiiian;;iiing address)
<br /> submitted to the Department of Conutterce. Personal information you provide may be used for secondary
<br /> • tu• ses in accordance
<br /> 1AplicOnn Information-ryas:Pril Information (It Oto *
<br /> 1. l __ cie *I
<br /> Pmperty Owner'a Name Parcel II
<br /> 1 d 1 6)-767 - ild- `Per6 -1,'
<br /> Property Owner's Mailing Address Property',ma on
<br /> 5 Y...11____M?)f■A- i,(,.. 1 ( Govt.Lot (
<br /> _. ._
<br /> City,State Zip Code Phone Number S Ph, /VW 1/4, Section 1 7
<br /> Oile,tdi,DO • •
<br /> __...aimmorti. . __. ...,. (circle one)
<br /> T____D____N; R_________F.or NV
<br /> .—_— ---•• -
<br /> II.Type of Building(eh : apply) . I.ot it .
<br /> Nano
<br /> 41-3 01 2 Family Dwelling •Num.• of Bedrooms L_-_- __ / Subdivision
<br /> Block it • .......,
<br /> ____
<br /> 0 Public/Comte'clot-Describe Use
<br /> -- .-- 0 CRY 01.- ---------
<br /> CSMNuinTicr 0 Village of
<br /> Li tate Owned-Describe Use. ____________ .
<br /> X.T4amn.id
<br /> ..._ . ...__,...... _......... ...._
<br /> III.Type of Permit: (Check only floc box on line A. Complete,lint B if applicable)
<br /> 4---------
<br /> Ncw System
<br /> 111 ...,._
<br /> LI Replacement System 0 Treaimentmoiding Tank Replacement only
<br /> 0 Other Modification to Pxisting System(explain)
<br /> _.....---.,.....„.,_._—,_...,.,....,„
<br /> ---- - .. List Previous Permit Number and Date Issued
<br /> II 0 Permit Renewal 0 Permit Revision 0 Changc a Plumber 0 Permit Transfer to New
<br /> Woo Expiration Owner
<br /> IV.'aplOf I:INKESS sten1/611 onentlpevlee: C.I_ LISLt all that ap ill ......_
<br /> ._
<br /> n Non.pr.ssuri70111•Gfound U Pressurind In•Grotunt 0 At-Grade touml24 in.of suitablo soil 0 Mound<24 in of suitable soil
<br /> U Holding Tank n Other Dispersal Component(explain) . ._________ 0 Pretreatment Device(explain)____ ____ •
<br /> y2issilotyrcatment AreitInfo rm.(iort!___ _ _ _._...
<br /> I esign Flow(gpd) Design Soil Application Ratc(gpdsf) Dispersal Arca Required(sf) Dispersal Area Proposed(at) System Hlevation
<br /> /(717.• ()
<br /> -
<br /> VI.Tank Info Capacity in • Total I/of ivIanufacturer
<br /> Gallons Gallons Units
<br /> New Tanks Existing mid. :a„ um tp 1 1 1
<br /> it o'
<br /> Septic or 1 folding Tank ley 0 0 , 6, .v I- / . r4q../ . .._
<br /> .. _
<br /> Ilipiing Chamber (0 ro f 65.sz . __
<br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for Installation of the PONVIS shown on the attached plans.
<br /> Plumber's Nemo(Print) __ m Plumber's Si mature MPRAPR.S Number Business Phone Number
<br /> 0
<br /> (t °--6 y. .. .,___-_•
<br /> Plumber's Address(Street,City,State,Zip Code) ‘._
<br /> / 1 5 co t Ochr (siN 1). r ■ 00,_ .1`),A_Ai e_ L.J•r 5 3 5"t.)- c'.
<br /> .---_._ :-- _
<br /> V111,Coun IDepartmo■LUse OrAY______ .... _ AIIIIIIIIIIIIIIIIIIIII
<br /> Pennit Fee Date Issued Issuing A g'en '',- tare
<br /> ;■APProvvi 0 Disapproved
<br /> ..--,
<br /> D Owner Given Reason for Denial $ gOg d 6 Ag. 0 , ,/
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> rIzIgNivillpoNIt\IIINE(N'i il.ii\litlIZA"'PLIfit(ii Villiol..1,,:s0ANN0ETCH001.11.Nt;1-Y.
<br /> / —______-----..,..— ,-------.- LIM ' • i. • - --
<br /> Attach to complete plain for the syctem and submit to the Comity only on porliuNT Ma la.
<br /> SIGHT,CONSTRIO6TION.011:A‘LNAM'YTINID.:ANSTIVIIA°°ANNCI;(3)17-Pi‘1-EiAcLri'F:AAy.
<br /> OVER.
<br /> R\:E--,
<br /> / De- ai 5 t 5 cy\\<, 50 i r‘
<br /> T :tri,7;RIGHT TO ORDER C. 3 OR ADDITIONS
<br /> / S1 )-6398 O .02/09)Valid ihru 02/11 In3.1701::Lif i I(Nr;aNNAtriAriF III So:FNI.1:,IN/N\SAS:11:At.)(A,L:
<br /> NFICI":'SSARY, ,MAKING THIS
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