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04/13/2009 14:42 FAX 6088508848 Septic Specialists lejUUZ chx_>! 1 <br /> c4:). <br /> ommorce..wl gt�t Safety end but s Division County <br /> _ 201 W,W,.n Su Av P.O.Box 7162 <br /> l'�biic Mi�tlil pane <br /> 9 n WI 53 07 7162 Sanitary Permit Number(t be filled¢t by Co.) <br /> \ D2O1OIL Ernnron,t��,r�tal1-:relth <br /> Sanitary,Permit Application sCtteTransaction Nrmrber <br /> In accordance with a.Comm.83.21(2),Wir.Adm_Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a'anirmy permit Note: Application forma for atatc-owned POWTS are Project Address(if different than mailing address) <br /> aubmitted to the Department of Commerce. Personal infommtion you provide may be used for secondary <br /> =ruses in accordotce with the Priv Law a.15.04 1 m,Stilts. • <br /> I. A..6ention information-Please Print A t Information ■ // - ,� u! <br /> Property Owner's Name Parcel# <br /> 0711-3 'f-- 'Say=o <br /> thf/ k t. c)an ear► 6n.t1weq <br /> Property Owner's Melling Address J Property Location <br /> P.o t box -S'i o Govt Lot <br /> City,State Zip Code Phone Number , , <br /> p 5 E /., s� /S Section �N <br /> a dt f�rs5O Ai- 1.v 7 6-3708 (circle one) <br /> T 7 N; R !1 E <br /> TL Type of Building(check ell that apply) ' Lot ii <br /> iii 1 or 2 Family Dwelling-Number of Bedrooms 3 / Subdivision Name <br /> Block# <br /> ❑PublidCou m reial-Describe Use 0 City of <br /> ❑State Owned-Describe Use ESM Number ❑Vrllage of <br /> Pil�� 1 0 Town of (� ,e, brc,t/� <br /> TEL Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A" -New System y Q Replacement System ❑TreatraenuFlolding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑PormitRenewet ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Liss Previous Permit Number and Date Issued <br /> Before Expiration •Owner <br /> IV.Type of POWTS System/Cotnponeat/Device•, (Check all that apply) <br /> g 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.Dispersal/Treatment Area ren tion1 ---• - <br /> red u <br /> Design Plow(gpd) Design Soil Application ltate(gpdsf) Dispersal Area Ra i (s <br /> f)(fj Arspersal Area Proposed(s System Elevation <br /> `1 Sv . 4 7 SOU 7 S 9c,s- <br /> VI.Tank Info Capacity in Total #of ' Manufacturer t—) <br /> Gallons Gallons Unite 3 a b ci <br /> New Tanks Erusuag Tank: a St v I _, q i <br /> acr SEt Pi *.a a. <br /> • <br /> (..rse Herding Teak p 0 G /OP0 I in'e ee A e- AC <br /> Dosing Chamber 6ao G n o <br /> VU.Res'onsiblUty Statement-!,the undersigned,assume responsibility for installation of the POWTS shown en the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Ken.reM'A Meier ) i.df 2`g'C°' Z'' Wily feV)S' .' iiF" <br /> Plumber's Address(Street.City,State,Zip Cade) <br /> 7 3G t !. r I.' -t,.'t- IaoLe L,cir 5-3 29 ' <br /> via.Conn /De.artment Use On <br /> Approved D Disapproved <br /> Permit Fee Date .■-• I • ,".•-� <br /> S t� � � <br /> ❑Owner Given Reason for Denial ; — I ,� . _— ►� <br /> IX.Conditions of ApprovaUReasons for Disapproval ■ <br /> ..C,,-..,:k:I lNl. 11-1E1-.:At i'FO,,'L. I1 . r CO1..!loTY <br /> EN. .,m?iJIEh17>;!F.r.[_1' i OES\1:-.'r t- "11 <br /> Ll,.LE FIX: -F'?:' :"S 1N PL,1. s OF Ear ECIFIC,= <br /> (IONS; AN Oi,A' 'SIi? S, FXAnnlnl A1 ION GVE•^, <br /> `tcli-iT,CONSTR ICTION OR ANY LAMA F''KAT MA' <br /> A s a to e s■plete Phial f o r thegste a mud sabmlt to the C.cep•aalY sa Payer 60I J04asdg pa 411 76iinstmTA!_I-ATI ON NC_RE S'':'lit• <br /> Ili-r:IGHT TC ORDER CHANGES OR ADDITIONS <br /> SHOULD CONDITIONS ARCS[MAKING TH:S <br /> SBD-639g(R 01/07)Valid tbru 01/09 NECESSARY <br /> • <br />