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Jun. 3. 2009 11 : 05AMi„t)T::=..-- , ', ,'. No. 0629 P. 1
<br /> r L ��”ldin Division County•tt
<br /> commerce.wi.ir i _ ty at►�il 1 gs
<br /> i JUM bl 4►!'Wasttlr3gtd i"Ave„P.O,Box 7162 bto L E=
<br /> i�i co tiladis n,�V 53707-7162 Sanitary Permit Number(to be filled i by Co.)
<br /> �7V
<br /> DePertn7eM of 00111 _ 1 _ f 0 0
<br /> Sanit r f '` fin it`'Ap1i1 cation Stale Transaction Number
<br /> Li accordance with S.Comm.tt3.211,2),Wis.Mm.gout,bubmussion ui•rnic to.-n:a,Lila'tppropriate go'emmental _
<br /> unit is required prior to obtaining a sanitary permit_ Note: Application forms for slate-owned POWTS am Project Address(if diffetent than mailing address)
<br /> submitted to the Department of Commen,e. Personal information you provide may bo used for secondary
<br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Slats.
<br /> I. Application Information.-Please Print AB Information
<br /> Property Owner's Name Parcel II •
<br /> ., w\(y\,".c ;-7,1--1-' ‘,-'^� �C� � .� (.'x('.;12.'- tY-4-2A 1,60
<br /> Property Owner's Mailing Address 1 �---- Property Location
<br /> P.0. \c - flj 11(p tiovt.Lot..._... —
<br /> City,Mute Zip Crete Phone Number t E 'A, to c o 'A Section 14-
<br /> N\LN .c.1k L..l.. r ‘-"-'i `7 t� t:5ct (p08.-aig _01-168 T N: R i• (circle one)
<br /> II.Type or Building(cl eck all that apply) Lot it C
<br /> Subdivision Name si{F}!or 2 Family Dwelling-Number of lie<Irtwttts .,
<br /> Block if
<br /> U Public/Commercial-Describe else {.I Coy,of_ ..._
<br /> CSM Number ❑ Village of
<br /> U State Owned-Describe Use ,
<br /> 12(.9P14-
<br /> ©7'uwn of `�
<br /> III.Typejtiacrmi . Check only one box on line A. Complete line II if applicable)
<br /> Pik;System ❑ Replacement System ❑Trratment/Hniding Tank Replacement Ouly n Other Modification to Existing System(explain) i
<br /> List Previous Permit Number and Date Issued
<br /> H. ❑ Penmt Renewal n Permit Revision CI change of Plumber t.i Pemrit'I'ransfer to New _
<br /> Before F;xpiration «r
<br /> _—..-1'V to 6TITOWTS-51 /C:nntponent/Device: ((:heels all that apply)�'' - -
<br /> ins-Kim la -'�PrOcsuri/ed In-Ground U At-Grade ❑ Mound:24 in.of suitable soil ❑Mound<24 in.of suitahfe soil
<br /> ❑Holding Tank n Other Dispersal Component(explain) ❑Pretreatment Device(explain) T_
<br /> V.Dispersal/Treatment Area Information: _
<br /> —
<br /> Desigra Flow(gpd) Design Soil Application Ratetgpdst) Dispersal Area Required Est) Dispersal Area Proposed(50 System Elevation
<br /> 7 5 cf p l c6"t 5 x'2-6;0 Sty,°� , gr �{ 1_cY'ck {
<br /> VI.Tank Info ! Capacity in 'Total 4 of Manufacturer °I Gallons _ Gallons Units g t°8 2
<br /> New F:vik�— t..%ISnIRY.I�im1:rc
<br /> Jp U ] A .
<br /> � P �tJ N N 44 t5 ,1
<br /> S_., oldingTaok /.........-- 11��6 ! (ti exit ( �?c1i)iFr<L� v _
<br /> _ /
<br /> 1]osintCltamber t� /000 1 'CC?.-r,V 1-, .
<br /> VII.Responsibility Statement- I.the undersigned,assume responsibility for installation of the Pow'rs shown on the attached plant, _
<br /> P tut nber's Nano(Print) Plum 's Si_ .tore 'riD E- �/ MP/1+•itttia Number Business Thane Number
<br /> <7..1t. -. .t y ,kJ toe, PLUMB(NCB ,2'2+ 2 4-1 9-2.0-47a-.%(5"
<br /> .2.0-4�]Q� (p(j"
<br /> Plumber's Address(Steam,City,Slate,Zip Code) /v
<br /> t,ilf) '`/40Ct> 6 a L k3a./ LfL.tu_ 1 1,,,2"0.-t- vsz,c9,vol._ S a r591f- j _
<br /> //f/
<br /> WTI.County/Department Use Only --
<br /> �Approved U Disapproved Permit Fee Date Issued— issuing ' : nt Si!,,oti i . `�� /On
<br /> n for Denial ` i. J� r-�� , _.__
<br /> n Owner Given Reason �/� (�,_ �
<br /> IX,Conditions of Approval/Reasons for Disapproval
<br /> _ ^—
<br /> DA lath to complete ins for the system and submit to the County only on piper not less than R in 1 t I ineha In star
<br /> --\q, "7"7 C i q - 5q 4 31� (fir oD
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