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w <br /> ..,. 111 dings D <br /> dr j . <br /> 1 f , ,' r >1 Ave.,P.O. .r: t�� o��i <br /> 'Mach •n W# 53707-7162 9162 x . <br /> `. r_ .'..,-.-a Naath fvtUG �s t—`�. �T t �" , <br /> t a 'ermif"• pp itca ton state . <br /> i4.-o.'`.-; 1.2 ),Wis Adm.Code,submission of this form to the appropriate govern tat <br /> .,t t o .owning a sanitary permit. Note: Application forms for state-owned P(t,r aro <br /> Project Address(if different tttart mailing address) - <br /> .; .f•-;i .w•-nt of Commerce. Personal information you provide may be used for secondary <br /> a -aocordenbe with the Priva Law,s.15.04 1 m,Stats. <br /> • <br /> ;jam x L°A lication Information-Please Print All Information �1rnY�)-{- ,R! . <br /> r Property Owner's Name Parcel# ■ <br /> Rob N Po-tty Ketryi <br /> Property Owner's Mailing Address <br /> Property Location <br /> 103 Sz.ts�t C . <br /> City,State Zip Code Phone Number Govt.Lot <br /> �S r IGI11� NIE '/,, WbAl v„ Section g <br /> COLS , 53�2e. .100--it,-,8 (circle one) <br /> II.Type of Building(check a that apply) Lot# T 7 N; R S E o/ <br /> pi or2 Family Dwelling-Number 4 s-'rooms 4 I Subdivision Name <br /> Block# <br /> - <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ID Village of <br /> gown of v1 IG{G)t- t i 1 <br /> ri ,:j <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ' 2New System . _ <br /> ❑Replacement S y stem ❑ Treatmen(/Holdin g Tank Re p lacement Onl y ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> . <br /> B. Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> JNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding'rank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil 1Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> l cX .LI 1p - — 1,512 �(:), 0 t — ,537. F.) ' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o 'n o <br /> .,J.. <br /> New Tanks Existing Tanks o y .n m ro <br /> a. U iii `n cn w 3 % <br /> Septicoer-l+ald ng Tank 12 12S( ` 1%-lc-.60.e.. <br /> Dosing Chamber <br /> VII. Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature IvtP/MI'RS Number Business Phone Number <br /> !`\YA rU'■l ii'J . kYt YNkC)1 L 41.r;! tO,!?'1.-,- 220165 `3-3-3 l- S 10-3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> x°13 c;11-, V_ \, ,\A-i'VI,V--e-e 1W\ 5?Js 7 <br /> VIII,County/Department Use Only __ <br /> pproved ❑ Disapproved Permit Fee Date I sued Issuing Anent Si '0 re <br /> ❑ Owner Given Reason for Denial $345'00 6/8/07 <br /> / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> • be- 0771? <br /> Ci-t}C -'9811/ 1.{ 45-.00 <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />