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4 608-831-8107 MEINHOLZ EXCAVATING 287 P02 JUN 11 '09 12:13 <br /> . i■ l� n ,etch alit.' IluiiiliuLs Utvulni; <br /> i Ls,I . 201 W.W ,•, ‘= Ave., P.O.Box 7162 1 irv.- <br /> 53707–7162 Sanitary Permit Narrt>xrt°be filled in by Co.) <br /> JUN 2 201' :.t,:- •.. 3151 <br /> De artfftt?nt Of COm L. . 1 . State Plan 1.D.Number <br /> • '3: ' llrtformati you provide <br /> In accord with Cotmh 83.21, _r',. )(m) Project Address(if different than mailing address) <br /> maY � ° '" 329/ <br /> s4�� <br /> I. Applicoa Infer–Please Print All Information Property Location <br /> Property Owner's Name <br /> t� fir,- (� V. SI•.J �/. Section 32 <br /> LY. . at �QVGri C1Mseget C1CJ N/!A'W Cod <br /> Property Owner's Mailing Address T 7 N R.0 E <br /> C5 Ti :rr= .l1<<., Telephone Parcel <br /> State Zip 323-o l�- ! <br /> City W \ 5 37 i I 0�°8 Lot# <br /> ¢1�b Subd"rysion Name/CSM J/ <br /> Type of Building all that apply) 4 6�a z <br /> �7 I or 2 Family Dwelling–Number of bedrooms ❑ City ❑ Village Township of <br /> ❑ PublidCottvrtercial–Describe Use <br /> ❑ State Owned– <br /> Describe Use M' I,- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if apptimebtle) System <br /> A. v e System ❑Replacement System 0 Treatment/Holding Tank Replacement Only <br /> ❑Other Modification to Existing Y <br /> O Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. ❑Pecmit Renewal ❑Permit Revision 0 of per <br /> Before Expiration Plumber <br /> IV. y <br /> of POWTS S•• : (Cheek tail that •':.,;;J•) Single Pass Sand Filter <br /> 7, on-Pressurized In-Ground 0 Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade SR+B <br /> 0 Constructed Wetland ❑pressurized In-Ground ❑Holding Tank 0 Peat Filter 0 Aerobic Treatment Unit 0 Recirculating Sand Filter <br /> to Chamber 0 Drip Line ❑Gravel-less Pipe <br /> 0 Recirculating Synthetic Media Filter ❑Leaching System Elevation <br /> V.Dispersal/Treatment Area Information: Dispersal Arcs Required(sf) Dispersal Area Proposed(sf) / <br /> VI.Design Flow(gpd) Design oil Appl Rate(gpdsi) I5I Z �'- <br /> ' Prefab cc Steel Fiber Pla <br /> �`b • <br /> Capacity in Total No. Prefab Con- Fiber Pla <br /> Tank Info Gallons Gallons of strn- <br /> Ell Tanks t; Units - <br /> // Teaks 25 <br /> Aerobic Treanrcat Unit _� <br /> Dosing Chamber (DSO assume responsibility for installation of the POWTS shown on the attached plans. -t�P/MPRSW No <br /> VII.Responsibility Statement- I,the undersigned,assn <br /> Plumber's Name(Print) � �Ol�'> <br /> •Airelv W- ^ - a Phone Number(Daytime)20 <br /> Plumber's Address(Street,City,State,Zip Code 'F31-1510.5 <br /> (.0l 0..114. IZ- r�k�a�•a�c c, la l 5.3 Ss 1 <br /> VIII. . . 1-.,. -...- t Use • . Date Issued Issuing Agent Signature(No S.-' ,• <br /> Disapproved <br /> Sanitary Permit Fee(incl / <br /> pproved 0 Owner / IQ jhQ❑Owner Glvrn 10 O/V r n for l fiurctalF:e) <br /> , <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> (to the Comity only)for the system on paper not less than 81/2 z 11 inches In size <br /> Attach cooPkt e plans <br /> DSI — a112 C \A— ` cf5,;-. 4-3co -- <br /> SBD-6398(R.01/03) <br />