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<br /> DEC 2 201,2 ' .i9
<br /> Q_O i' i.
<br /> commerce-mCgav Safety addings Division County
<br /> It. 1_,. 201_W::Wash gton ve.,P.O.Box 7162
<br /> i§cont. inr'Ho 53707-7162 Sanitary Permit Number(to be filled in by Co.)
<br /> Department of Cornmeree-,---11\LiErlErJ',2'-'!..ii..;_.'•-•. II"h
<br /> Sanitary Permit Apphcation State Transaction Number
<br /> In accordance with s.Comm_83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental p4/1,1 rotvr./.-(7e r7go•
<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.15.0411)(m),Stats.
<br /> I. Application Information-Please Print All Information P.----- .--nf- 7re-.....;
<br /> Property Owner's Name Parcel#
<br /> ,Sc.- f-1- ci (A)e_v, 5" fa_ c e---I.-1-- ot.c) --- 3c//- 8013- - c)
<br /> Property Owner's Mailing Address Property Location '
<br /> 26/ 0 S-f-e-4,--, 1)(0,:ic- -Sf ._ Govt.Lot
<br /> City,State Zip Code Phone Number N v., 1•4 v., Section 3ci
<br /> F fc-t--6--_, LJ ' - 537// LC.6; -- 04 g 3 T N 0
<br /> R 0 (circle one)
<br /> C' ; E or W
<br /> II.Type of Building(check all that apply) e___ Lot#
<br /> XI or 2 Family Dwelling-Number of Bedrooms ,) / Subdivision Name
<br /> Block-#, •
<br /> 0 Public/Commercial-Describe Use
<br /> - - 0 City Of
<br /> CSM Number 0 Village of
<br /> 0 State Owned-Describe Use .
<br /> / / -) 3 / ,i(--Town of Ve-i'D
<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 /> List Previous Permit Number and Date Issued
<br /> B. 0 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 0 At-Grade 0 Mound>24 in.of suitable soil Mound<24 in.of suitable soil
<br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> ,_V.Dispersal/Treatment Area Information: -
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
<br /> 7 5-° /. <-'' ' t .zia
<br /> VI.Tank Info Capacity in Total ii of Manufacturer e
<br /> Gallons Gallons Units
<br /> -0
<br /> New Tanks Existing Tanks z
<br /> L
<br /> 0 . ..)te. B tx.,P.. - —
<br /> a;u . sn 0 o...
<br /> Septic or Hpplag Tank /(>3—° - .....71e,-,..1--c— X
<br /> Dosing Chamber &OC.> ----- 60 t.) i
<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 'MPRS Number Business Phone Number
<br /> ATI et L,.; L h-ile,.,1,/z . _■4-----e_ 4.-).
<br /> .
<br /> Plumber's Address(Street,City,State,Zip Code) .
<br /> e.>t-; C-a-t /4.-‘" (...J---,(1---.-- (----). 5? .S-S 7
<br /> VIII.County/Department Use Only
<br /> Permit Fee Date Issued Issuing Agent igna c
<br /> j?(,pproved 0 Disapproved
<br /> D Owner Given Reason for Denial --
<br /> S .-7e 5q 2
<br /> l 2-- Y-06 At, C 24el/to--
<br /> IX.Conditions of Approval/Reasons for Disapproval ! )
<br /> ,■---. ,_,(6.-- f:0, tn/.. 'r. X . fi W / 6/'I '44;6(
<br /> IRONI'vIEN 1- . ''"---ri,i vi-A; .i• '
<br /> TLIABLE FoR,„„"1:- rIEALTh 00-E,-7-,.,',,vt--- COUNT}
<br /> IONS,.p, ,, '" DEFECTS 'Nur HOLD
<br /> L'iN 0 IN p., ,,-.
<br /> . _
<br /> P, IliFt, --.- - • zi. .A*4., - ••- PEr,,,
<br /> Attach to complete plans for the syslem and submit to the County only on papitmitif IN • ,t oN 00 „,„,,,,,ATIoN ov •-•I I IL,A.
<br /> THE
<br /> u°LI DG f 1 cT 0?OR OA RF TDERR1 CHANGES , .
<br /> 'arli SE 4,14frrk, , ,
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