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08/21/2009 06:54 FAX ;:625604795 OMalleyEom Ej001/003 6 " [) 1 , L AUG 1 32(}09 J .• L- commerce.vl.gov Safety Cuildin Division Co in Qn� fiSCOfls Sigton Ac,P.O.Box 71G2 n En�ironmental� 4h•WI 53 07-7162 Sani Co,) J Department at Co runCrerf San;tary Permit Application Sate ransactioNu(m�bcQr QQ In accordance with s.Comm.83.21 2),Wis.Adm.Code,submission of this form to the appropriate governmental Po W�S l �+v�� unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc Project Address(if different thanmailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Pri acy Law,s.15.04(l)(m),Suits. I. Application Information— 'lease Print All Information �t'e (2-ceNA.. Property Owner's Name f l'arccl k kiC 4 berls olz -6.w- 30.y- 44,69- 0 Property Owner's Mailing Address Pro}tcrty Location a v'- lei ale e -bin iQC_ Govt.Lot S9 City,State Zip Code l'honc Number ST----: %. s(r) / Section 3° uir\ P1C C I S3S9O aS-.32I (cite one) T C{ Ni R• I e.rW II.Type of B riding(check all that apply) Lot II Q I or 2 Fancily Dwelling—Numbc of Bedrooms Subdivision Name Block k grO0 kt-S Es-1--(- 5 ❑Publie/Commereial—Describe U ❑City of CSM Number ❑Village of ❑State Owned—Describe Usc_ �� tyi Townof S III.Type of Permit: (Check of.ly one box online A. Complete line B if applicable) • A IX New System ❑I p lacement System ❑Trcatrnentil folding Tank Replacement Only ❑Other Modification to Existing System(explain) D. ❑Permit Renewal ❑Pr lint Revision ❑Change of Plumber ❑Permit Transfer to Ncw List Previous Permit Number and Dale Issued Before Expiration Owner IV.Type of POWTS System/C Imponcnt/Devicc: (Check all that apply) • El Non-Pressurized In-Ground C Pressurized In-Ground ❑ At-Grade XrMound>24in.ofsuitablesoil ❑Mound<24 in.ofsuitablesoil ❑ Holding Tank ❑Other Dispel al Component(explain) J ❑Pretreatment Device(explain) • V.Dispersal/Treatment Area I aforruation: • Design Flow(gpd) Design Soil Application Ratc(gpdsl) Dispersal Area Required(sl) Dispersal Area Proposed(al) System Elevation CaOO o2.c 600 bar) . lo(. 77 VI.Tank Info Capacity in Total p of Manufacturer • Gallons Gallons Units o'a u Ncw Tanks ExislingTanks u e 2 2 u 2.g"7 o.U tot N • li'.O •As Septic ort rgTank /-g G /2-?.4. yy Dosing Chamber / S� — „.."-/e.._....42-. /� (o 6.5-.) / 4-, )( VII.Responsibility Statement- 1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. Pl bcr's Name(Print) Plumber's Signature MPIMI'RS Number Business Phone Number ettl ea m aI 2 _A----t- L.-) . -7-1-1-7, a0 l($ too? -83j- $I Plumber's Address(Street,City,SIa:,Zip Code) • 6e'13 C-63 K OQuna e c3z S-3Sgi± . VIII.County/Department Use )nly Approved ❑Disapproved Permit F D tc lss Q lssuin Apt ignature___,.....j.❑Owner Given I canon for Denial S Oa71#.......,,° IX.Conditions of owner Given anon for Disapproval SEE �owTJ OLJN( f /1,4(titAL �t ' °'d'.+ o �'� HEALTH LIABLE FOR ANY DE ECTS r p S NOT HOLD tT TIONS LAMS OR SELF • Attach:o complete plans for the system ant!submU to the County oa 11x#ne� r t �1V�6IATION OVER- ^ pQ z.7',��p RESULT IN OR AFTER IN��L�n�N AGE THAT q�A7 TH RIGHT TO ORDER CHANGES OR ADD RESERVE, • SBD-6398(R.01/07)Valid thru 31/09 SHOULD CONDITIONS ARfSE MAKING TH►mONS ChK-5/COD 9 NECESSAR}.