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<br /> L DEC 22003
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<br /> commerce.ligigtiv Safety dings Division
<br /> 201 W.Wash gton ve.,P.O.Box 7162
<br /> rtment of contrneree_n_lt il.,..r:1:: -;J:i!,:;:11thison, 53707-7162
<br /> isconiin, --1-3."-1-;
<br /> tt County .....7.‘
<br /> veL r■-..2-..-
<br /> Sanitary Perrnit Number(to be filled in by Co.)
<br /> Sanitary Permit Apphcation State Transaction Nurither 4,,, f,_
<br /> In accordance with s.Comm.8321(2),Wis.Adm.Code,submission of this form to the appropriate governmental 171144 (176/13- et e 71:3°
<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(1Xm),Stats.
<br /> I. Application Information-Please Print All Information 7rc.....;
<br /> Property Owner's Name Parcel#
<br /> cr, 5L3 fc_ c4--t-7
<br /> e_ .
<br /> ot:.ocs - q/- SoiS- - C)
<br /> Property Owner's Mailing Address Property Location
<br /> 02 6/b •-r-fre VI bc .,)c. sf .. Govt.Lot
<br /> City,State Zip Code Phone Number N IA, ”)i V., Section
<br /> F. f,..1-19(-- 5 L.") ' 5Th/ • T 0, (circle one)
<br /> C" N; R 0 E orW
<br /> II.Type of BuildiB (check all that apply) „...._ Lot N
<br /> );(.1 or 2 Family Dwelling-Number of Bedrooms, -) / Subdivision Name
<br /> Bluck-0,
<br /> 0 Public/Commercial-Describe Use • •
<br /> - 0 City of
<br /> CSM Number 0 Village of
<br /> 0 State Owned-Describe Use
<br /> / / ? 3 / )2r-Town of 1/4/9 e...-.0-0:,..‘c-......
<br /> . ..
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. ,) New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> _
<br /> List Previous Permit Number and Date Issued
<br /> B. D Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New
<br /> • Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground CI At-Grade CI Mound>24 in.of suitable soil 'Mound<24 in.of suitable soil
<br /> CI Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Desipflow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
<br /> 5-0 /. ) - 7S 0 75,1 ,:ic f ,--,_1.- s-, /c...
<br /> ... --,
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units
<br /> New Tanks Existing Tanks 1, E :2 g ZN 1 ils l'i
<br /> ei:O Fn. :, ,-;-, iz 3 F.
<br /> Septic or HOW Tank /‘50 ------ /6-S-C, 2_
<br /> Dosing Chamber &0c:> — s.,G cJ / (Z1
<br /> / .
<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 Isgl7MPRS Number Business Phone Number
<br /> fill LAY f-1%.: Li fri e-4 A L'IO - ),-'-`•/Z &.)*
<br /> Plumber's Address(Street,City,State,Zip Code) .
<br /> (e; 62.>1•3 C Tit 't R-c. (..,_).-- _„< 1---*— (- J. 57 ,sTh 7
<br /> VIII.County/Department Use Only
<br /> Permit Fee Date Issued Issuing Agent igna e , i
<br /> . )214pproved 0 Disapproved o)
<br /> 0 Owner Given Reason for Denial /7- y-08 , i.i., C Heixo---
<br /> IX.Conditions of Approval/Reasons for Disapproval i
<br /> --) <(-Cc: ie-Q In/.. /1 ./.: • /114/1//KfrI6rr P4A/V,
<br /> ...
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1)2 x ii inches in sire."
<br /> SBD-6398(R.01/07)Valid thru 01/09
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