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May 14. 2009 1 :57PM ii„);;--' ' `'. :L-,. i is No. 0512 P. 1 • <br /> r ii fi I�, <br /> COtlt111Q1Ce.WI.gOV i.. ■Sttel' �a� ildinlir ' .on County hh 201 W.Washington Avg.,P.(1{Box 7162 1} L <br /> /'�Q I 3bfadisrnz;.WI..5 07-71162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce ° ,�7,,;VifJ?t�l:ir.:;�t�� . ,iii-. <br /> Sanitary Permit Application <br /> stateTnmsaCtiortNumher <br /> In accordance with s.Comm.a3.21(2),Wis.Mm.Coda,submission of this form to the appropriate governmental 1._&_L,.---) (f2 <br /> unit is required prior to obtaining a sanitary permit. Note; Application forms for state-owned POWYS are Project Address(if differentthan 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(1xm),Stats. ((��0�f <br /> I, Application Information.-Please Print All Information l S 6t* Gl LL <br /> Property Ow cr's Name, 1 Parcel N <br /> Properly Owner's Mailing Address J Property Location II <br /> NI 2 2 b \j,j Id D K j. Govt.Lot <br /> City,State Zip Code Phone Number S', i4, S kl 'A, Section a9 <br /> r- .!..Rs-0 C �1 11e v t e t \MT 8 �08-1/zl-c=So`1 T 8 N; H � g E Q W <br /> 11.Type of Building(check all that apply) �� � <br /> I,ot# <br /> Of of Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block ti <br /> ❑PubliclConuuercial Describe Use <br /> ❑City of <br /> QState Owned—Describe Usc CSM Number[�(f El Village of <br /> 7 J 'Town of (Si <br /> am pae~4- 1 <br /> III.Typo of Permit: (Check only one box on line A. Complete line II If applicable) <br /> A. Eil New System ❑Replacement ❑Treatment/Holding'lank Replacement Only ❑Other Modification to Existing System(explain) <br /> System <br /> B, ❑Permit [I Permit Revision TE Change of n Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber Ncw Owner <br /> Expiratiun <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurizcd In-Ground ❑Pressurized In-Ground At-crude ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) -irtiatri Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information; _ y ry <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(si) Dispersal Area Proposed(st) System Elevation <br /> VI,Tank Info Capacity in Total N of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks lixlsling•l'anks <br /> Cie-Pie t rHolding lease / .C'0 _ r(sob l (or.n.k]U i)t 4K6.,-(a1 i-r(Q'r-i- <br /> Dosing Chamber <br /> VII,Responsibility Statement-I,the undersigned,assume responsihil's for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P nberjs Signat r MP/MFRS Number Business Phone Number <br /> 5e.-1 i L a_ved a<e _ r�^�x No 8S a. Gob•v�)- 131 y <br /> up— <br /> Plumber's Address(Street,City,State,Zip Code)ivt <br /> TVI .County/De t tment Use Only _ <br /> Approved _ Disapproved , Permit Pee 1 Dal Issued Issuing r <br /> _Owner Given Reason for Denial $ 2�y(+).�, `4 Jzi JoC� /1� � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Pro vL • c - Go o u'�'td U ( a4- C ae-� <br /> Attach to complete plans for the system mid submit to the ounty only on paper not less than 81n x 11 Inches In sine <br /> DI -75 7L) Lli k' Lg 9 / 4783 .ao <br /> SBD-6398(R.01/07)Valid thru t)1/09 ch K-42 a 93 ,it. 95: 0 0 <br />