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�� � C E � �1 [ .sDivision-1 c 7 86L C L- f 38 3 C <br /> commerce.wi. Safety and : County <br /> it <br /> 201 W.Washingt' P.O.Box 7162 /�a n <br /> is ca n s AUG 1 2 °n° ll ' 07-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Camm e 5/8 /07 <br /> Sanitary ' • A"7' :e State Transaction Number <br /> . . n tt�i:4t on <br /> In accordance with s.Comm.83.21(2).Vis. AdmallikOLIttlieffItillchithillthrm 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 /> purposes i1-n accordance with the Privacy Law,s.15.04(1)(m),Stats- ( _An n <br /> I. Application Information-Please Print All Information _ h <br /> I I-at/doe! (d' <br /> Property Owner's Name Parcel <br /> J - r ue . ch o 4 1 - a-2- - q r 0 -b <br /> Property Owner'. ailing Address <br /> Property Location <br /> ocation <br /> 2 0 0 I ) ea 1 Q t�+n I Y Q e p Cn Govt Lot <br /> City,State <br /> Zip Code Phone Number <br /> I e ' C , - W 5 35-,7 7 (circle one) <br /> II.Type if Building(check all that apply) Lot T 7 N; R // E or W M...1 or 2 Family Dwelling-Number of Bedrooms LI 3 Subdivision Name <br /> Block <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use �3 � <br /> CSM Number ❑Village of <br /> I i i-ToHn of (--0 a e G%d <br /> /:2- Y3 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ' <br /> New System ❑Replacement System ❑ treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ' List Previous Permit Number and Date Issued <br /> G Permit Renewal ❑Pewit Revision ❑ Change of Plumber U Perieen Transfer to Nev: <br /> Before Expiration -Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> gNon.-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 M.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpj dsf) Dispersal Area Required(at) Dispersal.Area Proposed(sr) System Elevation <br /> ( GU < <,( /Soo %SOd qv,c) 913.5 <br /> VI.Tank Info I Capacity in Total _of Manufacturer I I s <br /> Gallons Gallons Units I r, y o <br /> U <br /> New Tz� E ng Ta k; o 5 u P c ' r IT, 2 <br /> c U to co (% <br /> . Sept _HoldMg Taal L ( t'z 8'G I I I I ( <br /> Dori,s CE a-,her I I I I I /'` P Li C P I I I I <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber'aName(Print) Plumber's Signature lvE/IVGRS Number Business Phone Number <br /> Plumber's Address(Steet,City,State,Zip Code) <br /> 7-�C ( 10,r 1 U fi Du�c_ Ltil S 5 -a ( / <br /> VIII.County/DepartmentUse Only <br /> Permit Fee Dat Issued Issuing Agent Signe e 'KAppreved U Disapproved $ .-_ <br /> ❑ Owmer Given Reason for Denial d 7 4/,.3.1.<,/riot a i N< , --,v IX.Conditions of Approval/Reasons for Disapproval <br /> (1 33 17/7, 3 ()7-5-3) <br /> r#J100 <br /> 2-37 '1 %. x-31-(v Lief S <br /> ieh to complete plans for the system and submit to the County only on paper not less than 8 1G s 11 inches in size <br /> A It <br /> i S <br /> SBD-6398(P..01/07)Valid thru 01/09 <br />