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Jun. 22. 2009 11 ;41Ag- t'.-,'''..'=--: , ..u{ No. 0772 P. 1•
<br /> � 411
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<br /> carne , •.:-- Safer' ijd l�uildinp,s I)ivision County
<br /> %l,i 1.,R JUN 1 7 2f W.$;tishhltigton Ave.,P.O.Box 7162 A ��
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<br /> Mtiilisoh,WI 53707-7162 Sanitary Permit Number(to be lilted in by Cu.)
<br /> i7emparb lent of oml rq° 5e=2030289
<br /> `t • C i'i ;,;• . ii iY t • Coate Transaction f__,, Number Sanrttary `P >lit A'Il,lieation
<br /> In accordance with s.Comm_83.21(2),Wis.Adm.Code,submission of this form to the appropriate govcrl.mentai _
<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.15.04(1)(m),Slats. ,
<br /> I. Application Information-Please Print All Information
<br /> Property Owner's Name ,` h Parcel 4
<br /> .TN's\ 1E b k i C 6. $ �t�C-I+Q )C 4 .t�7' V-C' ; O 5 051/i-' z't-._ '7l 5 -[i
<br /> Property Owner's Mailing 1A1ddrecs Property Location
<br /> 5 2.c C A oc 1-1 1-- k.c5RZ7 Govt.Lot +,^b
<br /> City,state Zip Code Phone Number ,C,F /, sL ye, Section /2_
<br /> 10 l --rtv.12,h.Ca o LP/ ,;.s., 3 tqy (circle ono)
<br /> II,Type of Building check all that apply) 1.or# 1. g N; K / "por W
<br /> IL nr2Familyl) tilling-NumberofBedrooms 7 ..--_. , 40 CI Subdivision Name c
<br /> .7gw-L'.e∎r A:.
<br /> Block if �QC7i? c.) L+-�`te.`7_ i 1A
<br /> ❑Puhlie/Comitmen al-Describe Use
<br /> - .. ❑City of
<br /> ❑Slate Owned •Describe Use CSM Number I 1 Village of ^
<br /> h]-Town of c`s1t2.t 411.cAlxN(_.... _.__..__
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A.
<br /> lIBNew System ❑Replacenteut System U TreaUnenlillolding Tank Replacement Only ❑Other Modification to Existing System(explain)
<br /> B. .. n Permit Renewal n Permit Revision u ❑Change of Plumber ❑Permit Transfer to Ncw List Previous Permit Number and Dale Issued 1
<br /> Before Expiration Ommner
<br /> IV.Type of POWTS System/Cumponentlt)evlce: (Cheek all that apply]
<br /> ❑Non-Pressurized IIl-Ground ❑Pressurized In-Ground U Al-Grade b Mound',24 in.of suitable soil U Mound<24 in.of suitable soil i
<br /> 1 ❑ Nolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> V.Dispersallfreatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Ratc(gpdst) Dispersal Area Required(sf) Dispersal Arca Proposed(sl) System Elevation
<br /> O i 1 _ <pe,c5 4.0'z.o 9 ,J--
<br /> VI.Tank Info Capacity in Total 11 of Manufacturer
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<br /> Gallons Gallons Units
<br /> Newimnks 1:344ing'Pinks P O 1 ra
<br /> Septic or lloldineTank ' w(rl,
<br /> Dosing Umber l`.liL1 aril) l roe.;, .ltcsr..aCj,, l.r
<br /> VII.Responsibility Statement- I,the undersigned,assume respousibility for installation of the WA TS shown on the attached plans.
<br /> Plumber's Name(Print) Plum 's Signature MP/M1211.8 Number Business Phone Number
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<br /> Plumber's Address(Street,(:i�ylatc,Zip Code) ,
<br /> Lt_) e, �(�il-- Lc-k !- , L041- &7'()Le P I (,t) l :50`i4 •
<br /> VIII.Count /De artmcnt Use Out /
<br /> . Approved U Disapproved Permit Fee Date Issued ` Issuing 0 cnuattrrtr-
<br /> 4 Q
<br /> __ n(honer MI=Rouson for'kolal_ S V QS' 4/ZY O ,� a ►' 4—_�. ,-
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<br /> IX,Conditions of Approval/Reasons for Disapproval .N\
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<br /> Attach to comptete plans for the system and submit to the.Comity only on paper not km than 4 Iris I t lac Wain
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