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i 1 u)Is__ _, , ., ft_, t1 \7 _15_, <br /> • L.— <br /> ..r - <br /> • <br /> . II I I . -- , , • , I <br /> I <br /> • commerce.wl.gov LSafety and Buildings Divisiort 1 County 10 <br /> , 201 W.WItthipgton AVe:,P0,....7Be)i 71621 <br /> isconsin :-m,o,son.v4 5370=---462.. Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce 6 / E 14/ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a_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 /> purposes in accordance with the Privacy Law,S. 15.04(I)(m),Stns. <br /> I. Application Informs• -Please Print All Information <br /> Property Owner's Name Parcel# <br /> ProPrty wner's Mailing AddrR <br /> C‘)1A ov z - 09/- 6.943a -0 <br /> Property Location <br /> N 1 i , kl Gesk ri Govt.Lot <br /> CinStre _":Code Phone Number <br /> NG A N-C.:- 'A, Section CI <br /> r . <br /> . T C( N; R___12Ctner1).V <br /> II.Type of Building(check a that app ) .- Lot# <br /> . Subdivision Name <br /> XI or 2 Family Dwelling-N ber of B • .oms ? <br /> Block# <br /> 0 Public/Commercial-a- ibe Use <br /> 0 City of <br /> CSM Number 0 Village of <br /> 0 State Owned-Describe Use <br /> )1/Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) . <br /> A. rew 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 P it Transfer to New <br /> Before Expiration . Owner <br /> _. <br /> IV.Type ofPOWTS System/Component/Device: (Check all that apply) _ <br /> El Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suita e soil lifl(ound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretiea ent Device(explain) <br /> --------- , <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) -Design Soil Ap I ication Rate(gpdsf) Dispersal Aregired(s0 Dispprsal Area Proposed(s1) System Elevation <br /> liS.- 0 (0 ( 0• likS U7 ()\tAl i‘ <br /> VI.Tank Info Capacity in Total II of Manufacturer <br /> 2 C <br /> Gallons Gallons Units <br /> .in E. ra.g <br /> New Tanks Existing TaLdis. .2 0 •-- ta I-, `- r. "in" <br /> 1! ' rt:c.) et vs <br /> C---2S)r • <br /> Sep c Holdmg Tank 1 DCO , <br /> 14:9° _ Atoka_ <br /> I <br /> Dosing Chamber n <br /> --...__ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTSrEINwn on the attached plans. <br /> Plu 1.. 's Name(Print)' P I Apip Signature MI' RS Number B iness Phone Number, <br /> . <br /> I ' <br /> -7 ZOter-z Z o423 . ? <br /> Fl r Addr. tre.et,g ity,.tate,Zip Cod,) <br /> )1...1` Use it, frt•Nh C, <br /> VII .County/Depart ent Use nly <br /> p <br /> LT 5'3725- . <br /> , . <br /> ' <br /> Permit Fee Date Issued lssui Agent Si;natu <br /> *c7kpproved 0 Disapproved S CC <br /> -...1 <br /> 0 Owner Given Reason for Denial <br /> , . <br /> -,.----- / <br /> k.TsLEINII INAG\IBI;REA0NIFNLij);TorkI1 Rt.:EN:A:TONT:1w.OMISSIONS,cpssHSETAEIFIO0NPAENPLCTRST0HO,SFt:DIXAANA,01 APPROVAL,PLANS NANNA:OsTmETIOA0cHuNRoohosuLTPN:J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> .iEE ITSELF <br /> T_ISFEmI CLAAF,r. <br /> ttach to complete plans for the system and submit to the County only on paper not less t <br /> DB-„775A3 s 4 1 4(.9 iltsUrr IPcOR AFTER INSTALLATION AND RESERVEE <br /> THE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> • <br /> SBD-6398(R.01/07)Valid thru 01/09 SHOULD CONDITIONS ARISE MAKING THIS <br /> NECESSARY. <br />