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"May. 19. 2009 9:28AM No. 0534 P. 1 <br /> commerce.wl.gOv Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O,Box 7162 ()4,,,e <br /> tiisconsin Madison,WI 53707-7162 Sanitary Permit Number(to he filled in by Co.) <br /> DeeppOtttmmenntt of Commerce -57 7 I <br /> Sanitary Permit Application - _ StateTrraannsaction"Numb <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental `�t" f 4 �� <br /> unit is required prior to obtaining a sanitary permit. Note Application forms for state-owned POWT I are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may bo used for seeondaryS-, j v <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stets. <br /> L Application Information-Please Print MI Information . <br /> Property Owner's Name Purcol# <br /> ALL 13ase-, 62'f1 — .�3 .� S'.s 3 _ es <br /> Property Owner's Mailing Address - Property Location <br /> /5) re• lA/ etN S-"" <br /> City.State - - Zip Code Phone Number /tJt4)+/y 51-'4`) 1, Section .0-1 <br /> c1( osS Pt-AtN, 1 w1 �'3SZ$ CC a) 2.-3S- °V T N; R.:11 E <br /> IL Type of Building(check all that tip <br /> let 61 r--- ^"'R <br /> I h Z Pamiiy Dwelling-Number ofBedr is Subdivision Name <br /> Dlo,k# <br /> Q PubliNCon roeroinl-Describe Dan ❑City of <br /> ❑State Owned-Describe Use___ _ CSM Number__�v <br /> --- ❑Village of <br /> - — [fs35wn 0 f S'v.4'-PAL-ht at e <br /> Iii,Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. '> i cw System ❑Replacement System ❑ 1rcattenbloldin gTank Replacement Only <br /> ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ©Change of Plumber List Previous Permit Number and Date Issued <br /> ❑permit'Transfer to Now <br /> Before Expiration Owner <br /> N.Type of POWTS SystemlCon jJonent/Device: (Check all that apply) ._ <br /> fil-loa <br /> es.surized la-Ground ❑Pressurized In-Ground ❑ At-(trade ❑Mound>24 in.of suitable soil ❑Mound<24 In.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) .T. <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdet) Dispersal Area Required(A) Dispersal Area Proposed(sf) System Elevation <br /> VL Tank Into Capacity in Total N of Manufacturer , <br /> Gallons Gallons Units ' <br /> Nlow Tanks Existing Tooke Ci ''M. i ' 1 1 <br /> Septic oeikeatila'lank ' .,/‘ G'° ------- fir 6c) / DALMAKAY X <br /> Dosing Chamber <br /> Vit Responsibility Statement-I,the undersigned,assume zee.•nslb ....fur Installation of the FOWTS shown on the attached plans. <br /> Plumber's Marne(Print) Piz ■ a:ignature MP Number Business Phone Number <br /> MICHAEL 1'AC`OiLt C I 225-065 (603)655-3510 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> MARSHALL PLUMBING,260 CANAL ROAD,MARSHALL,WI 53559 <br /> VTR Conn /De.artment Use Oni <br /> Approved ❑Disapproved Permit Fee Date Issued Issit"rg_Ag it Si re <br /> ❑Owner Given Reason for Denial 5.? S.47 7-12_o7 _ C 1074440.-- -- - <br /> �IX.Conditions of AppruvaUReasons for Disapproval <br /> . <br /> Attach to complete plaits for the system and submit than 8 m ill Inches In size w <br /> S13D-6398(R.01/07)Va 4011/09 4E 5 <br />