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<br /> DC 18 20n9 ; til4i'
<br /> commerce.wcgdv; Safety anti ciings Division
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<br /> a. L. - 201W:Washilton ve.,P.O.Box 7162 County .----h
<br /> itiscon4iin :. :, „, ,.,.,,,;.„,, :Mason,WI13707-7162
<br /> ._ F.; ;, r-,-,----t- - Sanitary Permit Number(to be filled in by Co.)
<br /> '57 8'
<br /> 97,2 0
<br /> Sanitary Permit Application State Transaction Number
<br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental
<br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for 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 (---7)
<br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. ______
<br /> I. Application Information-Please Print All Information C--- r or r 1 t</a/V /(1--
<br /> Parcel#
<br /> C./
<br /> . .. ........... ,.......... ..,--
<br /> Property Owner's Mailing Address Property Location
<br /> ,3 5 (,) j e e__ / Govt Lot
<br /> .-City-, te & Zip Code Phone Number
<br /> 5 cc) v., S,A.-/ % Section 13 0
<br /> .....)..)e rd/e/ f- 6<-)7 T ., T y N R l(cene)
<br /> i
<br /> II.Type of Building(check all that apply) Lot#
<br /> -1-or 2 Family Dwelling-Number of Bedrooms c c) 7 Subdivision Name
<br /> -7-?r., 1 /
<br /> Block# c=j;;K iJr o 1 ((;)/41--We/1z-)
<br /> 0 Public/Commercial-Describe Use
<br /> 0 City of
<br /> CSM Number 0 Village of
<br /> 0 State Owned-Describe Use
<br /> killown of R/.ti/0 /
<br /> III Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A' 41New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> List Previous Permit Number and Date Issued
<br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> c' on-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade a 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 /> d-,2 •5----e-) 9,7,y
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> ..' A.
<br /> Gallons Gallons Units ., 3
<br /> New Tanks I Existing Tanks ,E-1 '.'
<br /> __.
<br /> 5 9. 2 •E.; , 2 '13 in
<br /> ei T., T, -7 5
<br /> Septic or Holding Tank c_c_y_c,, A/tea
<br /> Dosing Chamber itteYde -14
<br /> VII.Responsibility Statement-I,the undersigned,assume responsibi',- for installa on of the POWTS shown on the attached plans.
<br /> Plum,, 's Name(Print) __) 4) PI umber's i t...hire , MP/MPRS Number Business Phone Number
<br /> ----__ ) ceue, i.fr? f/cti .;d_ 70.7 601? )9yil?-) 7,
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 7 1 C 1 0 a,-1 J,:i C,:w. t- Oa,e Cc r
<br /> vw.County/Department Use Only _
<br /> Permit Fee Date Issued Issiing t*.eha. i 4
<br /> Approved 0 Disapproved
<br /> '.•-•q/- A v /44 0 / CZ
<br /> a Owner Given Reason for Denial .._.7)()Z-- - ,4 41# A...."..,
<br /> k ' -- -
<br /> IX.Conditions of Approval/Reasons for Disapproval caT-F- (VC--(7-0(1,-BM -
<br /> -Co-li\O---.0 fiN CV 4 !`f/VCI -45:6- E--ri-Lcont-c-cl-,
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
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<br /> qr\K — 401-617--
<br /> SBD-6398(R.01/07)Valid dim 01/ 9
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