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608-831-8107 MEINHOLZ EXCAVATING 208 P03 APR 20 '09 15:37
<br /> iL
<br /> APR 7 2009 1 �•
<br /> cormmeroe.wl.eov S and Iiuddings Division County n
<br /> 2201-• ' gt4n Ave.,P.O.Box 7162 U ex,i'v e.
<br /> 1229.11.9it_
<br /> abhC is,,f'i t `dli oison, 537Qi-7162 Sanitary Permit Number(to filled in by Co.)
<br /> virarir�er taw " _,I
<br /> Sanitary Permit Application State TransactionNinnber •
<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 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 /> • .• .^in accordance with the Privacy Law,s.15.04(1)(m),Stets. .
<br /> I. Application'Information-Please Print All Information
<br /> PVeiv Owner's
<br /> 6r,,Name Mat-,r Parcel 311---42a t/3-5-
<br /> Owa. -Mailing Address Property Location
<br /> ,, Rl:� f k4 5. . 1/-0,,, % Govt Lot 3�
<br /> City,State Zip Code Phone Number J W %...3) l section
<br /> t a1 ks r. UR. S(r {circle one)
<br /> s3 a � T � N; R $ �Deus
<br /> II.Type of Building(check all that apply) 3 Lota
<br /> €1 or 2 Family Dwelling--Number of Bedrooms Subdivision Name
<br /> Block# SAN CS,. a R ) is Es4,
<br /> ❑Public/Commercial-Describe Use '�—. ❑City of •
<br /> El State Owned-•Describe Use am Number ❑Village of [�
<br /> �.Town of Se'f1h9 Pve.,1i/,
<br /> III.Type of Permit: (Chet . .... mu. ■. ■ e A. Complete line B if applicable)
<br /> ❑New System ' Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> il ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New -
<br /> List Previous Permit Number and Date Issued
<br /> Before Expiration Owner
<br /> IV. 4 e of POWTS stem/Com• .nent/Device: Check all that a• •■ •
<br /> El-Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil
<br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> V.D D. . rsal/I'reatment Area Information: • -
<br /> Design Flow(gpd) Design Soil Application Rate(gpdst) . Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation •
<br /> 5 0 ,y . 11 D.5 11 8 g9.7rg3.°1, qv.o; 9a.8'.
<br /> VL Tank Info . Capacity in Maus Units Manufacturer A
<br /> p U
<br /> New Tanks Existing ranks V i L u I
<br /> •
<br /> Septic orHoldingTank . 1000 1000 I MQao112 of -
<br /> Dosing Chamber (,50 --. (.Sb 1 4.. tF
<br /> VII.Res•onsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> jt) 1 P •,... 's Si re MP/MPRS Number Business Phone Number
<br /> Plumber's Name J'ti k 1� %� 1^ ii0
<br /> 1/S+ e�w d L , �3�B 3
<br /> PI .- s Address(Street,City,State,Zip Code)
<br /> C4i �. �'v 4w '' , W kvr.4,6e,4 w� 535 7 r►.IA1
<br /> VIII.Corn /Department Use Ohly
<br /> Permit Fee Date a II :.,;et a3 . 1
<br /> 1a� pproved ❑Disapproved $ /���k��l j�ii J�,��
<br /> ❑Owner Given Reason for Denial 4 :7. /pi `� . U_
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> IN C ',NTlNGTHISA. Pc.I01t;L 'he,.tr. {;1-,.•-
<br /> • L vV P.ONMEN i' L�'t:. I. 1 :') ,
<br /> LIABLE FOR ANY DLFE -:,iN Pi u -:7i y ;if•,,
<br /> Attach to complete phase for the system and submit to the County only on papertpia 3 � k s.r,h A 9,a I i
<br /> �, n i• l`t)�V ti j'31.1 Vl\:,,a7 i y r• ,.
<br /> 1HL.RIGHT 10 OPr :p��-{rrnl - • x,
<br /> SBD-6398(R.01/07)Valid thru 01/09 +
<br /> . SHOULD c0NDiTlo;0 y Ri`t;i41. ,. • 1
<br /> • Ae!v . : i NECESSARY
<br />
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