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Sep. 16. 2009 7:59AN f1 l5_lb i i U is -, • No, 1332 P. 1 <br /> U .• <br /> • <br /> Commerce,w .g n �yatit 3u1l ings Division County 1 <br /> S�p '281 .(_� shiuti_- fietif ve.,p-O.Box 7162 O Cs.A� <br /> 'L+/+An Medisot,W1 .i3707?162 Snail <br /> Department of Co ere PUt NC Health iv100 A <br /> Sani v nitb_ ry State Transaction Number <br /> In accordance with a.Comm.83.21(2)',Wis.Adm.Code,submission of..thf iss�form to the appropriate govemtnental <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 Conunorce. Porsonat information you provide may be used for secondary 54"-1 <br /> in i i is in accordance with Ilia Privac Law,S.15.04(1,m Slats. �AA 10 ` <br /> I. Application Information—Please Print MI Information) Ak iS S C`-'y t U <br /> Property Owner's Name Parcel N <br /> Gkl ( . - L€ J\ch► u 002-22}4--e000-3 . <br /> Property Owner's Mailing Address Property Location <br /> ().\' . R-Jr- Its ok _ S-k- Govt.Lot M1M1- <br /> City,State Zip Code Phone Number �/, S vy Section J <br /> ilA6 ySd� W l- T3 Jd t .S\ - `l S L% • (circle one)SE <br /> II.Type of Building(chccltailthatapply) ~ Lot T. . N; R iior>l <br /> . I1.1or2 family Dwelling-Number ofBedrooms Subdivision Name - <br /> Block q <br /> • <br /> - <br /> El Public/Commriercial--Describe Use ❑City of . <br /> • <br /> ❑State Owned-DescribeUse CSM Number ❑ Village of //�� <br /> kr Town of,. .d <br /> & 1 r A <br /> M.Type of Permit: (Cheek only one box on line A. Com(slete line B if applicable) u� <br /> A' fhhh <br /> New System ❑Replacement System 0 Treat lent/Holding Tank Replacement Only ❑OtlserModification to Existing System(explain) <br /> —4 <br /> .8. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner • <br /> IV,Typo of POWTS System/Component/ cvicet (Clhectt all that apply) <br /> &Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grado ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil • <br /> ❑holding Tank ❑Other Dispersal Component(explain) El Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) t Dispersal Aran Required(al) Dispersal Area Proposed(sf) System Elevation <br /> (-, -9 11).- 1,1x' 7° '_ %I. 7 <br /> VI.Dunk Info Capacity in Total S of Manufacture <br /> Gallons Gallons Units <br /> New Tettka 'Existing Tanks 6 G 1 <br /> ScpdcorHoldingTank 00 ,. 1 tbp /A,� <br /> � 1 i cA <br /> Dosing Chamber � • <br /> VII. Responsibility Statement-I,the undersigned,assume ras onslbnky for Installation of the POWTS shown on the atlached plans. <br /> 'Plumber's Name(Print) Plumber's Signature MP/MPRS Number Pusiness Phone Number <br /> ANAT G..2, M \ ul. 1r�2 t Itil )`)d ( ` 5 _ 3 t- 710 <br /> Plumber's Address(Stmt,City,Stott,Zip Code) W <br /> Lit 3 C .T N IC' (-,0,-,-,6.. .e Lk–.L S GI 7 A <br /> VIII.County/Deparlment Use Only • I <br /> pptoved ❑Disapproved Ponnil FeO Date I ue I .,n_ -+?i <br /> �. <br /> S 10 9 ..:0.1! !.' �' ' <br /> ❑Owner Given Reason for Denial �� � <br /> IX.Conditions of Approval/Iteasons for Disapproval <br /> Attach to complete plan!for the system and submit to the County only on paper not teas lion S n/z x I I inches in size <br /> D - 277( <br /> ehR— 5240 a . <br /> SBD-6398(R.02/09)Valid uU 02/11 • <br /> • <br />