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. . ... <br /> ,risi it...e,: C I F_P., i_ Wi - <br /> 1 <br /> commerce.vi/Leccii- ------ ---------Safe -an iiildings Division <br /> Iscon,Airi Li% 1 0 2 rivadis°9 <br /> ti. <br /> Department of - 201 lickli.Washt4.*Ave.,P.O.Box 7162 <br /> ,,ji ; r 53707-7162 County <br /> PaPlA <br /> S.,-..• '.., ,.• N ..bsanibifielled• by Co) <br /> 0 5 <br /> —!---r- <br /> Sa4taiy Pennit ATticatiolpi State ransaction Number <br /> In accordance with s.Comm.8321(2) Wis.rAihi..:.COtiol.sii144isi `Ot„this form to'.the appropriate governmental <br /> unit is required prior to obtaininkirtabittit'Y-AWE.-•44O4',Apaiiiittilon..fonnsjfor 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(lXm),Stats. <br /> L Application Information—Please Print MI Information . 1O7 <br /> Property Owner's Name Parcel# <br /> CO thy 5den it Yin 0(IZ- on -BSI)-o <br /> Property Owner's Mailing Address Property Location <br /> 3017. 161 1314 Govt.Lot <br /> City,State Zip Code Phone Number 4/it/ 'A, 'A, Section / <br /> CAM lat deo i LA T N; R /15 *352$ ca-zzo-2Z32 4cuslks one) <br /> 6 C CriorW <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling—Number of Bedrooms 3 I Subdivision Name <br /> Block# <br /> II Public/Commercial—Describe Use <br /> 0 City of <br /> 0 State Owned—Describe Use CSM Number 13 Village of <br /> ..-2 <br /> 1 5 <br /> 1 , ( X Town of e Arls4higifC, <br /> - <br /> III.T1.100 P.' '.,•. (Check only one box on line A. Complete line B if applicable) <br /> _ <br /> A. ,1 <br /> 1 JELNew SisM 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. I Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Com_ponent/Device: (Check ell that apply) <br /> PLNon-Pressurized In-Ground 0 Pressurized hi-Ground 0 Al-Grade 0 Mound?24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> LI 0 • q Mc 1/Z4-- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> 4,r'')' § <br /> crsep;t9Er Ming Tank 1 30 0 <br /> i ;°0 I , bcilmAray ec,„•,),. A <br /> Dosing Clamber <br /> VII.Responsibility Statement-I,the undersigned,assume reSponsibility for installation of the PMI'S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signalre hIP/MPRS Number Business Phone Number <br /> lePre., .T. liv4fe ''t .frif-)7. 2° 5...e 77 53Z? 920-98g. 713 7 <br /> Plumber's Address(Street City,State,Zip Code) LI P.O. <br /> eox 568 4.4re 0'04 NI: 5. 56/ <br /> r <br /> VIII.County/Department Use Only <br /> Permit FeO ____I Date Issued Iss "H! :,.---'r Si 14, ,- i <br /> -Okpproved 0 Disapproved <br /> ' 'flP/ , <br /> 0 Owner Given Reason for Denial _ $345::— i 6 twO .....„4., <br /> 1 , <br /> IX.Conditions of Approval/Reasons for Disapproval ,•— N <br /> •43/1,-Llizlt. t•SCe-0— ,E=6"Z%L. tAA-Vc ggt.L.6 - 4 , 4A-'31414414., <br /> I( cic ..15-1 62..„.ov sP.....4. ti= eg-% A Pre ik, 4 , / <br /> Attach to complete plans for the system anal submit to the County only on paper notices Map tl tiz x 11 inches issue <br /> SBD-6398(R.02/09)Valid than 02/11 <br /> . . - <br />