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15 IE G E li w Et .. 1.\. <br /> ii. ,7 <br /> commerce.wl• NOV fafe?P r d Bui die iit <br /> !Division County n — <br /> 201 W.Washington Ave.,lO.Box 7162 11,J\ <br /> �+f��1„L+ Jai 5370 7162 Sanitary Permit Number(to be filled in by Co.) <br /> - Department of Comm■ FubliC NOalirl iv <br /> Environmpl_ttal.oc.lth i g 03 <br /> Sanitary Permit Application Suite 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 /> ^ ES5A in accordance with the Privacy Law,s. 15.04(1)(m),Stars. VA N G SS A 1/./Ay • <br /> I. Applicati , All Information _ <br /> Pr rty O s Nam gp Errierpf$ <br /> eS �G Parcel# <br /> V.Q,V V�rA b�- - !a 5l� Frawley Dr. ogil <br /> '363 ao35 -0 <br /> Pr erry <br /> Owner ilin A dr Property Location <br /> Ian ,,� Sutn Pralrt"Ci li 53Sgd <br /> yrw--- Govt.Lot Ski <br /> Ci State Pret,P.-t._ p Code Phone Number r , y,1 y, Section t) <br /> t)-� YV T (circ ne) <br /> U.Type of Building(check all that apply) Lot# T N; > E o W <br /> / or2FamilyDwelling-NumberofBedrooms Subdivision Name n <br /> ////`""”' Block# I tf• >k-o t ((,'CXX 11.-5 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> li Town of f'-''S 4-a <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 . Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground CI Pressurized In-Ground ❑At-Grade CI Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> `U Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Dosig Flow(gpd) Design S 1 Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o ci ,�, o <br /> U V - <br /> New Tanks Existing Tanks o c g , ° ,e m <br /> C!Cr.) C rn i=.8 w <br /> 4 Septic. Holding Tank i n 0 J I 1 1l �� 6 <br /> Dosing Chamber L?4)J <br /> VII.Responsibility Statement- 1,the undersigned,assn r onsibility for installation of the POWTOrvn on the attached plans. <br /> Pl is Name(lint) Plumbe i tire ( •RS Number Business Phone Number <br /> j 1rt , Ir• tJ ��LZ„ fez `lam' 6z3 - `ts 17 Pl tier's Address(Str t,5tyt,,State,Zi Cod <br /> V P� yab Lu.. _0,s. 14 5z s— <br /> VII].County/Department Use Only <br /> Permit Fee Date Issued Issuing gent Signal e _ <br /> Approved ❑Disapproved / n Q� <br /> ❑Owner Given Reason for Denial S 33 t I / OS/ <br /> ��, �- <br /> 1X.Conditions of Approval/Reasons for Disapproval —�� V <br /> ” 6RaAF_ 17. `REAva4 u,.it P. E r e' - - <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> D6— D.110(o Cl'IK- 4G357 77 _ <br /> i SBD-6398(R.01/07)Va'id thru 01/09 <br />