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Aug. 25. 2009 11 . 16AN 1 E k ll VILE , <br /> t No. 1206 P. 1 <br /> • <br /> �'-— c mmerc..w1.''`' Safety alp cgs Division County <br /> f ��, <br /> ii' ; N1 e.,P.O.Box 7162 I : - 17"iii. <br /> ' � � I, so I'il 3707-7162 S ;fi• ,) Co.) <br /> Departmof Coen _ •_ <br /> - Sant:L r : :� lj� �3P-..ti do State TraaneactionNumber • <br /> in accordance with a.Comm.83.21(2)Wis.Adm.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 POW'S arc Project Addreee(if different then mailing address) <br /> submitted to the Department of Commerce. Poisoner Information you provide may be used for secondary <br /> purpose in accordance with the Privacy Law,a.15.04(1xm),Slats. C 4" <br /> 1< Application Information-Please Print All Information _. <br /> Property Owner's Name <br /> Parcel ii <br /> 0 A r-i A ''T-dvi C Z (C 0‘07 (:) -157.)-,.S" <br /> Property Owner's Mailing Address Property Location <br /> 2/es 0 try{. P q <br /> City,State , -• Zip Code Phone Number _C' 11. 4-LA, Section 1 <br /> _Her 4 3 (AA 5 .572... }X?"• 75411 T ',G N; A__2 -E <br /> IL Type of Building(check all that apply) ` ] H <br /> r.►{J <br /> Q 4Family Dwelling-Numbs of Bedrooms Subdivision Name <br /> • Block fl <br /> ❑Public/Commereial-Describe Use ❑City of <br /> ❑State Owned-Describe Use C3M Numbery ❑ Village of - _. . <br /> 6 " ®Town of -, `�C" er- <br /> IIL e,'':.-o •e ,, ' (Check only one box on line A. Complete line B if applicable) <br /> `#" BiW$ysta El Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modiflealion to Existing System(explain) <br /> Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Phumber ❑Permit Transfer to New List Pre <br /> • . Before Expiration Owner — <br /> IV, a ofPOWTS S stem/Cent onent/Device: . .4 all tom \, •1 <br /> ❑Non-Pressurized lo.Oround ❑Pressurized ln-Oround I.: AI'Orede ❑Mound?24 in.of suitable soil ❑ Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain ", ❑Pretreatment Device(explain) . <br /> ' <br /> V.Ms s,,rsaI/Treatment Area Information: — <br /> Design flow(gpd) Design Soil Application Rate(gpdat) Dispersal Area Required(af) Dispersal Area Proposed(sf) System Elevation <br /> 4 tro 0.L t e n Gs / na4 qq c <br /> VI Tank Info Capacity in Total P of Ivfanufacturer <br /> Gallons Gallons Units .8 <br /> New'ranks Existing Tanks U i <br /> a <br /> s ii.ec idiag Taok / -2,c-t, `~ /2.5° 61245-r' X <br /> Dating Chamber 7_p 750 Mill G24 5tr~ <br /> VII.Responsibility Statement-I,the tinders 4 .,assume responsibility for imatallafon of the POWTS otm on the attached plane. <br /> Plumber's Name(Print) u PRS Number /Business Phone Number <br /> 3:104037n 6 e d e 1,* l5 t l ei (oz t 4 41 Q a <br /> Plumber's Address(Street,City,State,Zip Code) --"r or <br /> do-4.6" lit • -r (to. Mk p s d'o O z. r-2-71 1 <br /> VIM County/Depa ,,',t Use Only <br /> Approved ❑Disapproved Permit Pee Date Issued Issuing and Signature <br /> ❑Own agog t--- S-'2i-o- /�j D <br /> ,( I <br /> Omer Given for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attith to comptsta pions ler the syoteus and submit to mho County only an paper net la+then 5 Mall lnche.In.Ira <br /> SBD-6398(R 01/07)Valid thru 01/09 <br /> chK-51sao . <br />