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t.O i I\li <br /> 1.l <br /> afeTy and Bui aag�I ivision County <br /> a ,.:�,,,,,i .wl-g 201 W.Washington Ave.,1 O Box 7162 kJ y - <br /> C O n S I 1 . . _ th$i 5370"-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ]e Fubiic ri_:altil Ivies <br /> Department of Comm <br /> rnrironmpnta1 Oeaith i 5 l g (03 <br /> Sanitary Permit Application Slate 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 . <br /> N r CC <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. y�'C/v ES5A kyky <br /> 1. Applicati.• - ' • • 'rint All Information <br /> Pr...-rty0 "s Nam / gp £rater if seS LI,G Parcel# <br /> t.V '∎ �cLr• I b . - lb r• oqi/-3O3 ao3Y--o <br /> Pr.perty�Owner ilin_A.dr Sul", Prcurt•'e1 V11 53Sq b Property Location <br /> Cj 1 Y pis r�i� 'L Govt.Lot 514) <br /> Ci State p Code Phone Number Nw , f y., Section <br /> j-fir\ PrCk.i tr Vv T (circ ne)T Ct N; I E o W <br /> II.Type of Building(check all that apply) Lot# <br /> " <br /> ( or 2 Family Dwelling—Number of Bedrooms \\\ <br /> \ Subdivision Name n <br /> 1111 Block# g lr• -O l 6 Q i`Calk-S <br /> ❑Public/Commercial—Describe Use <br /> ❑City of • <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> lie Town of E't'S"\ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 'New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B- ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration 1 Owner <br /> ?i(Non-Pressurized El IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: _ <br /> Desigp Flow(gpd) Design çPPlicationRate( Pdsl) Disp sal Area Required(sf) Dispersal Area Proposed(sf) Syst vatio�Soo l Sys <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ` - <br /> U <br /> D u <br /> New Tanks Existing Tanks °P c> , y a _ <br /> n. U y <br /> rn u.U a. <br /> Septic Holding Tank 12 C j2,0'; I ( <br /> Dosing Chamber W r fi *`` <br /> VII.Responsibility Statement- 1,the undersigned,assu r onsibility for installation of the POWT wn on the attached plans. <br /> Pl is Name(Plint4 Plumbe i ure MP RS Number Business Phone Number <br /> PI Pc ber's Address(Str t,5viel <br /> ,State,Zi Cod <br /> p c, y'A6 ( ( c 14 537z r <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing •gent Signal, e <br /> Approved ❑Disapproved 9 , <br /> ❑Owner Given Reason for Denial $ I I / 'O S ���,_-. NorAllraiM <br /> IX.Conditions of Approval/Reasons for Disapproval -4111.41/ <br /> %ca--S4t;r_L jklekTIE ILE—hR-e-ii ---r---01A-L-LAt- sZ'''\I \ <br /> -AT (ORkt\C___AREPN kka7" PEMATA UtaL7-;:s-C;P-kE -- -f.J .E.- - .7 I y <br /> Attach to complete plans for the system and submit to the County only on paper not less than t IR z 11 inches in size <br /> D6- 1110(o C-kK- 46 35 7-// <br /> SBD-6398(R.01/07)VaAid thru 01/09 <br />