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608-831-8107 MEINHOLZ EXCAVATING 154 P02 FEB 19 '09 09:32 <br /> p) ltr <br /> , <br /> ^ FEB 1 3 2009 ! l i <br /> cotmmerce.vf.$toy Safety and busldings Division County <br /> 1 201 W.Washington Ave.,P.O.Box 7162 ' <br /> tis 1 S^O fl S` ; .-,-- ;- . , NM(�dtffiDtt.WI S3707-7162 Sani it Nit mbcr(to be h ued in by Co} <br /> DepatRsraM of CoreavagC wirt,. „;;.' ';.. �''..� _ lC5J' O <br /> State Transaction Tfum <br /> Sanitary Permit Application <br /> In accordance with s.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 POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Slats. AS 4„t v.J/- ,.... <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name a Parcel X <br /> ...SV 1'-i .to aJ• .�'IG�./e., Siiv..t:J�, r..a.Q' o5 ` bSGQ"303-c.368- 0 <br /> Property Owner's Mailing A css ✓ Property Location <br /> fly 8 <br /> Sole o1cL �.dot/ Y1J /2.0c. ,..0 74 /0/ Govt.Lot <br /> City,stale Zip Code Phone Number SC y.,Sc.) %,Section .3a <br /> �ck e.1..Jo/7 �/'. - (circle one) • <br /> (check T S N; R OD EorW <br /> U.Type of Building(check all that ap Lot p <br /> {� Q Subdivision Name <br /> J"'I or2 Family Dwelling-Number ofB•• •• 0 1 nn <br /> _... Block It c4.-rr."-sue Or?CAL. • <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> 0 State Owned-Describe Use !� <br /> -- Town of `Ser. /15 tl/��e-/GR- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) • <br /> A. <br /> 'Ncw System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> E. ❑Permit Renewal o Permit Revision 0 Change of Plumber ❑Permit Transfer to Ncw List Previous Permit Number and Date Issued • <br /> Before Expiration Owner <br /> IV.Type of FOWPS ystem/Contponent/Devicc: (Check all that apply) <br /> %Non-Pressurized ln-Ground 0 Pressurized In-Ground ❑Ai-Grade ❑Mound>24 in.ofsuitable soil ❑Mound<24 is of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DlspersaVCrcatm ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(sf) Dispersal Area Proposed(si) System Elevation <br /> G 0 U . `I- /c...0 .c /S■o(D A4..°Mil '*//4• <br /> VI.Tank Info Capacity in ' Total II of Manufacturer 8 r <br /> Gallons Gallons Units 8 _ <br /> New Taaks -Existing Tanks u .1; I <br /> ss U w <br /> :tg y y ii.o n. <br /> Septic or tioldias Tank j a.8 6 /2.h t 2 <br /> , 1 je /2.4.- )e.Dorne annum (, yo <br /> (p,S-v / aL _t[.. <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation 1if the FOWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbers Signature istrIMPltS Number Business Phone Number <br /> , t.kft...a W. A r ice•-i-z. .....*--•e. ea.). . ) 30 i6 S 668' -P�/-ff 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (c1+13 e.-11-1 /.. LJc .•.;,f•..e, t.): . S1 7 . <br /> VIII.County/Department Usc Only / • <br /> moved Disapproved Permit Fcc Date Issued Issuing cnt Signature • <br /> 0 536Z.6O 2-!6- <br /> O Owner Given Reason for Denial 0�,,' r f e, Y <br /> IX. <br /> Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plain for the system and submit to the County only on**,tfitll/t .*ap;if;14#tlrlaehes;.In site <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> ChK- 411(01 <br />