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. . ler , -, , <br /> commerce.wl. ii':' jut 2 andBliilclinggDivision County <br /> • <br /> V 4.,i 01 W.Washmiton-Ave.,P.O.Box 7162 P A a E <br /> i sco n s I n L sont W1 53707-7162 Sanitary Permit Num (to be filled in by Co.) <br /> - Department of Commerce PI:' _ 518 D ') <br /> State Transaction Number <br /> Sanitarermit Application y� �,� <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental DANLr 1°'°14(7r <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(1Xm),Stats. lr-�TZ <br /> 1 Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> M A-2V_ L l z€ l_ T424 i 6 IN 7 -- o(aZ -- Y7 g> — a <br /> Property Owner's Mailing Address Property Location <br /> 2_2 p--7 WovD5t(7 C)2. <br /> City,State Zip Code Phone Number NI. ) y,, ^JlA--) 1*4, Section ,v, <br /> Q2..cSS 0LPLtiS w( ,:c 3s-27 (�a8) 2.25--- 81iy <br /> IL Type of Building(check all that apply) Lot# T 6 N' R- ' E <br /> O'1"or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CI State Owned-Describe Use CSM Number 0 Village of <br /> 4 ®Town of 5 PR WGJ A�4 Lt <br /> ILL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑'1�ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade 13'1CIOund>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(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> 6 6° a. s / 0° 17'(3-7S---- /t S- I <br /> VL Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units B o <br /> gc u ~ -TA Tanks Existing Tanks d B m ..g. <br /> 0. 0 n m. <br /> u.O P. <br /> Septic of-Heeding Tank r3 coo 13 o a ) 0 A-1.AA A.P--P'r X <br /> Dosing Chamber 7.0) 7.- I D Po-eM 4.4P3 )C <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 �,(' liSTIMPRS Number Business Phone Number <br /> 1k v 01)4%-i' j LLE _ .:ctLS 2_27 sZs' 4.08) v`Es-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> S01 COtAAnAER_C E__ P1Lw`r.j V ELeO J A. , c--- I .53Sg3 <br /> VIII County/Department Use Only <br /> KApproved Fee Date Issued Issui Ag Si !RQ Approved ❑Disapproved $ � ?---2-Y °63 � <br /> ` \ ❑ Owner Given Reason for Denial 7e3 — C <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> X-F-C '9 t .7-f- /' flier% P -�IA.,r <br /> Attach to coin fete plans for the system and submit to the County only on paper not less than 81R ill inches in size <br /> DB- a1595 C iK `131b3 <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />