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Y,1 I' • of • l• i <br /> 17 L ;r. <br /> 1-47910 3 • <br /> commerce,igoy v tL 2 qty anditlildings Division County <br /> H201 W.Washington Ave.,P.O.Box 7162 q/ <br /> S� � 'n Madison,WI 53707-7152 t`� <br /> Department Coti.r»er>ce i, Sanitary Permit Number(to be filled in by Co).vnultlt>i tit Nea1U1 1 <br /> Sanitary rerm1f p tip C1p won SttatteeTrrans(actionNumber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental / -`'t/K. -# g es03 <br /> unit is required prior to obtaining aasanitary permit. Note: Application forms for state-owned POWTS ere 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. 1 S.O4(lxm)_Sats. <br /> I. ApplicatjonInformation-Please Print All Information 1 2 ‘/4 4.,-J- <br /> Property Owner's Name <br /> Parcel# O„L7 _ __ <br /> Q.t- 15� t r`Vt.' pv*545 LL <br /> (3-4#7-C7'75 - <br /> Property Owner's Mailing Address C-0- 1- i <br /> /� 4 /5 i „� / Property Location OF 10 X05 7_g�7d-/ <br /> City,State v Govt.Lot <br /> 1p Code 446,01i°Phone Number �j <br /> 1"-t" 53 g / ` Y s & '/� S6 '4 Section) <br /> v�/ (tire ) <br /> II.Type of Building(check a I that apply) Lot# T N; R • ! <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ubliclCommercial-Describe Use V144)10°- C <br /> �(`` <br /> V.IA.'$1'1% ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> yTowri of r3,`rte <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> I A. 1 <br /> ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> r <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 hi-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> o <br /> ❑Pretreatment Device(explain) <br /> Tank ❑Other Dispersal Component(explain) <br /> V.DispersaVFreatment Area Information: <br /> 1gn Flow(s Design Soil Application Rate(gpdsf) Dispersal Area Required <br /> _ e9 ('� Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of <br /> Gallons Manufacturer <br /> Gallons Units U <br /> allons <br /> New Tanks Existing Tanks ° ° g <br /> `-i 0 ° u <br /> C V {�E. <br /> Sepnc.� coo —_ a U y y t: C7 a <br /> Dosing Chamber l - ,5.. <br /> i X. <br /> I <br /> VII.Responsibility tate-rent- 1,the undersigned,assu res i i sibility for installation of the PO <br /> P ber's Name(Print ` wn on the attached plans. <br /> ia� 1\, Plumber/ : . _ <br /> , 1� .R5 Number Business Phone Number <br /> Plum 's Address/,�etreet,Crity, tate Zip Co,• <br /> d �� 7Je <br /> p �✓ O /lU / 4"! 9 <br /> VIII_County/Depart rd / 5 " 1 2('6 r�' /'0 <br /> ant se Only i <br /> X4.pproved I I <br /> roved Permit Fee Date ssued C <br /> ❑Disc <br /> PP 13 tao Issuin gent gnat <br /> 0 Owner Given Reason for Denial �� 12.- 3--,0€3� c Ve447--- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> lef s TEp 4 eMY HLD/n/G T/-}✓re _ <br /> PRos27y `r1(4, -- c � ��iPo�/� �X�,2Ff i��i o `l_ <br /> l /YE c -r Ta ,e4 <br /> (CEc✓672 t�'�/c s � / <br /> li— / - 2�,0 q D Ae54 awY N?Go o- _7 <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)Va ikl.lhru 01/09 <br />