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Ap r.t20. 2009-�10:47AM -. . 1 ,it Ub-- i� ► I I n1\- `toiat�- No. 0313 P. 1
<br /> - I t _..APR 1 6 2009 I �,� i� �•
<br /> ' oommerce.wl.gr 4 ► Safety and Buildings Division [Cmtnty
<br /> I i � �j , 201 W.Washington Ave.,P.O.Box 7162 .L) /14e
<br /> [ t nil l Et „w, Madison,WI 53707 71.62 Sanitary Pcmiit Nlwlber(to be filled in by Co-)
<br /> - oprrr t5f11 of Coinmaroo pp rr��
<br /> Sanitary,Permit Application .. state Transaction-Numhar
<br /> In accordance with a,Comm,83,21(2),Wis.Adm.Coda,submission of this form to On apptoptiate governmental
<br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stale-owned POWTS ara Project Address(ifdiffcrt:nt than mailing address)
<br /> submitted to the Department of Commerce, Peisortal information you provide may ho used for secondary
<br /> .purpose,in accordtmcc with the Privacy Law,s.l5.04(1)(n1),Slats.
<br /> I, Apptic;ition Information-Please Print All Information /� �
<br /> Property Owner's Name Parcel 0
<br /> o r e- r /4 (1/114.--t-
<br /> 07b '` _..°.. DO'S oZ
<br /> Propetty Owner's Mailing Address Property Location
<br /> 6 7 j61_,4c,Kea_ '77--- __ Govt.Lot
<br /> City,State / Zip Code Q Phone N[unber /�i�� y, Section 6
<br /> ���`b/ G( C�, _� ', / ��i�`tC�L�" 7 y� CScircle one) l
<br /> —
<br /> T 7 N; R Q K or W
<br /> a.
<br /> Typo of Bu Ming(check nil that apply) %...f3
<br /> Loti! .
<br /> I or2 Family Dwelling Number ufiiedronma `� SubdivisioiName
<br /> Dtock0 r C_Ae -r woe) d
<br /> U Public/Commercial-flescribeUse r—` y
<br /> n City of --.
<br /> ❑State Owned •Describe Use =BM Number 0 Village of
<br /> Mown of !/LlViek ,iCv
<br /> Iii Type of Permit; (Cheek only one boa on line A. Complete line R if applicable)
<br /> A.
<br /> U New System ❑Replacement System Tre atmentfliolding TistibildeeeutosiOnly n Other Modification to Existing System(explain)
<br /> B. ,i st Previous Permit Number and Date Issued
<br /> ❑Permit Renewal ❑Permit Revision ❑Change of Plumber Plubet• ❑Permit Transfer to New f
<br /> Before Expiration Owner
<br /> IV.'iypc 0fPOWTS SysteniJCompoiieuUDcyice; (Check all that apply) _
<br /> QGNon-Pressurized In-Grntmd lI Pressurized In-Ground ii At-Grade ❑Mound>24 in,of suitable soil 1:1 Mound<7;4 in.of suitable soil
<br /> LI Holding Tank Li Other Uisperaal Component(explain) _ CI Prctreattueut Device(explain) •
<br /> V.Dispersalll'reatinent Area information:
<br /> Design Flow(gild) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(at) System Elevation
<br /> VI,Tank ftlfn Capacity in Total II of Manuterhtrer
<br /> Gallons Gallons Units o-5./
<br /> �c",
<br /> New Tauica r?xistinaMusks - d 05 _5 d
<br /> 2 u
<br /> . a U rn ti m w(7 P.
<br /> Septic of H»A[w�ttt»k ._— .---
<br /> Ic��D 1c�.TCS t..._ -�e`t J�
<br /> —
<br /> hosing Chamhrr
<br /> Vii.Responsibility Statement-1,the undersigned,assume respons Mir for Installation of the POW1:S shown on the attached plans,
<br /> Plun1 Vane(Print) - Pl 'S . .ibn f MPMIPRS Ni mew Business Phone Number -
<br /> +1
<br /> Plumber's Address(Street,City,State,Zip Corti) _ L
<br /> '36t 1 Oar i 1n C01-1-w'1- Daiit? (.t1r 5-$.5- A9
<br /> VII i,Couuty/Bepsrtmenl trio Only _
<br /> /l7lpprnyed ❑Disapproved
<br /> Permit Pee Date Issued Issuing Agdn[ eharo
<br /> f__ ❑Owner Given Reason for Denial r �` Qq ���y �/
<br /> TX.Conditions ofA pprovaUteasnts for Disapproval
<br /> EXk S t /7.- rr. eat
<br /> .1 0,6 irj lirrv7'1N( i its A(�i r A.,DAN ;(7JA!t Y
<br /> ,�1, i\! ti.}ii 1;i.II1 t:ll)f': F`rI_::',,','I(}l l')Ii;,f'`! f-
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<br /> t I':f'()i1:1i�"' i)(::I-i..., ,-.
<br /> .' �,I,.,Il i t'i '1Nf?,i."t=t,Attach to coat lets l tas for thes stem and subnrtl to the('nun nnI oo .t eenotl $rt2 r s, di A F:,/ 1 A 1 P P Y tY y P'P � �,t..z{.11`��itjfbl(���"J'� t� �lt`lEt`}„! ){\t{)111.:;t-
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<br /> Purr,p R.ev ew it 11 OQ JI.1 li\ t1,IA11 IF:i�Iis1:';f'AfiAiION AM);. ,.;
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<br /> -SDl)-6398(1Z.01/07)ValEdiluuOt109 •
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