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608-831-8107 MEINHOLZ EXCAVATING 015 P03/04 AUG 28 '08 14:39 <br /> tr -• <br /> U,1 i 1 11 ►�+ e Z.a 'NO-) DeTa 07i?/ <br /> 1 t AUG 2 1 411; -� Division County <br /> tiSCO. ,4- t , .10 • . . • Ave..P.O.Box 7162 C:14ne, <br /> S a W I 53707-7162 S a n i t a r y Permit Nuabv(to be Aced is by Co.) 1 <br /> IT r s 4111 -State Traaaeoer NrO ter <br /> S! 1 • rermi • • • • y Ion <br /> In accordance with s.Comm.8321(2),Wis.Adm.C ode,submission of this fora to the a p raptitst:g.teuacmdl 1)i41 C /9-q4/4.1 t4aZ°-7 <br /> unit is required prior to obtaining a slay permit Non: Appil:mien fora for sYtnorwwi rows me Project Address(daftness dna nsilaig address) <br /> submitted to the Department of Cem meree. Pascual iris anion you provide tray be used for secondary <br /> Bpi meet in aoeadwee with the Privacy Law,s.15.04(I)(a),Stets. <br /> I. Applicatisu lufarsstioo-Please Print AO l.faa.tstiat N. Riley Ra, <br /> Property Owner's Now Patel 0 <br /> pVier\ e- _ a-177- -sf: -o <br /> Property Owner's Mailing Address Ply Location <br /> K316 Pwre \ha..• Govt Lot <br /> City State Zip Code Phase Maier beASEA, MENE,Section Z <br /> U .w (aide ewe) <br /> � ,at, v.)1.11 3 _ T N; R I E'ev W <br /> II..Type of IBaildimg(clack all teat apply) 1 La d <br /> . <br /> l�1 or 2 Fundy Dwelling-Number ofile roams Subdivision Name <br /> f l sk i. _ • <br /> ❑pnblie Cosw eicial-Describe Use ❑City of <br /> C <br /> ❑Stare Owned-Describe the SM Maier ❑VtllaRe of <br /> 'Town of S el y401tei <br /> III.Type of Permit: (Cheek only me box w line A. Complete ire B if.ppkable) <br /> -"• [(New System 0 Replacaue'4 System 0 Tteatasendfioldimg Tame Replacement only ❑Other Modiftation to as:Wing System(explain) <br /> B. ❑Pamir Renewal T❑Permit Revision 0 Clwivy of Plumber 0 Permit Trssfer to New List Previaa Permit Nwber ad Dtse/sired <br /> Bey Expiration Owner <br /> IV.Type of rOWTS SystessICommement0Devier (Cheek all OM <br /> 11112 <br /> y) - <br /> ❑Non-Preamrhed In-Grand ❑Pressurized In-Ground ❑At-Grade QTbfasd>24 in.°isoiable sal 0 Mound<24 in.nitride soil <br /> • ❑lidding Tank ❑Other Dispersal Composes*(explain) ❑Petlrraanent Device(explain) <br /> V.DispersaVPreatwrart Area Lionisation: <br /> Design Flow(gpd) ' Design Soil Appliance Raae(gpdsf) Disposal Area Required(ef) Disposal Area Proposed(d) System Elevation <br /> toCI, 1.b tot-10 - <br /> VI.Task lafo in (tea Units 11cr s <br /> ° 6 .3 o <br /> New-rake i 7aala a a <br /> I <br /> 0 v►P <br /> a.O o. <br /> se}tie.ritr1IL$Tale IZob — 129, l WA* X <br /> -nosing Oonsel o (..-S0 — V-X, 1 H X <br /> VII.Resp.wsibility Statement-I,the ra/asgaed,assume respo.diiity far isit. 'a.ante POWTS shave so the atfaeied places. <br /> Plumber's Nape(Print) Plumber's Simonet MPlMPRS Number Business Phone Number <br /> I' <br /> -/ W I.ICrrkd t- .L_. LA.‘-h. 7 ' - °.S31.8403 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (eel3 .CM. e rva , w i 7 <br /> VIII.Caaaty/Depattmeat Use Only <br /> Disapproved ' Permit Fee �� Date Issued Issri A �jJ <br /> A ❑Owner Given Reason for Denial s / 77440._____." �1 -- <br /> - IX.Conditions of Approval/Reasons for Disapproval <br /> LA rtsd to t..rtlete plans For rte spleen.d ales'to dot a•wr only on pow wet lam thaw 4-in s iJ met' ` 1 <br /> SHD 6398(R-01/07)Valid thru 01/09 r,.1ECES ;4N" i F4!' <br />