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t v <br /> �� an 10 l � C ..-# i-i a-a l 5 <br /> commerce. • Safety aid B dings Division County ix <br /> ' JU_ 1 f)126Q/ash' Ave.,P.O.Box 7162 q h P <br /> 'scon adisor 53707-7162 Sanitary Pemlit Nu • r(to be filled in by Co.) <br /> Department of Commerce • 51g I l0 G <br /> uI A`G h jeu t M Stater : tion Number <br /> Sani- 2 <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are ' oject Address if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 3 2 5 3 C 1111310.4.e_ Re* <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name nn Parcel# <br /> S 4∎,vx a let c. Al ;c_.-el.P K4. t..A.."tin 070e-- 3a3-- 4i/68-/ <br /> Property Owner's Mailing Address /� Property Location <br /> W 47944 136e Y e t1 v) kJ r% uE• Govt Lot <br /> City,State Zip Code © Phone Number Si-C U 'A Ss 1,, Section 3 QL <br /> e�QC`k° C-4^6'k. t F j,l S . 5 '1 1 � T -7 N; R p (circle one) <br /> 4 II.Type of Building(check all that apply) Lot# Ea E or W Li x or 2 Family Dwelling-Number of Bedrooms OC Subdivision Name t <br /> Block# G 1 a c i e v's 1'e h 1) <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0/Village of (y I -tpp <br /> LWTown of n'1 r ail le -oil <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. XNew 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 ❑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 /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> (00CD 0otoo 1 boo I O �' <br /> .0 (8,3 S psi- 9,S.3C• <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ' , G o v <br /> u <br /> New Tanks Existing Tanks '� g u t' Y 1 i 1 <br /> c U h g rn w 5 a, <br /> Septic or Holding Tank /a e° /.7 60, / h7eat:YE (,/ <br /> Dosing Chamber / - (co / <br /> J / eQ • i- <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Busine Phone Number <br /> 73/eyi K'Af/4 IZZJ 2b/23,c �n F62-3736 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> re . &x 3 43 .9z-erMv(I, /°v'/ 53 5 Z <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing • • nt Si. :• , <br /> ❑Owner Given Reason for Denial <br /> $ 337• - 7/161 0? i' " Z, <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> • <br /> SBD-6398(R. 01/07)Valid thru 01/09 <br />