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t ... <br /> • � ar �� Z_ F ECEou <br /> `t C.*- 44 ail 3Ca <br /> ccmmerce.wLg Safety. . dings Division County <br /> J l L 1 10 1 as u'1 , Ave.,P.O.Box 7162 t>A a E <br /> 's c o n� .'.' , 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Deperbnent of Commerce P Hoc 5/8 0 'F <br /> Sanitary State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> ��required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> Department of Commerce. Personal information you provide may be used for secondary C L l tiT O ti rep. <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name <br /> intent/447Z_ jj\\�� Parcel# <br /> T4E Fz SC 1-�' _� ly ! A -"J C,--•-•-• P/4 2.-Cc t, <br /> Property Owner's Mailing Address Property Location <br /> . 7471z CH&RoHEEAil W-7 <br /> City,State Zip Code Phone Number <br /> -•5-t=_ %, 5L.-) y,, Section <br /> BEAPER min P1 6 _ '1 574®®/3 <br /> IL T of Building # T 9 N; R !a E <br /> Type (check all that a . <br /> 8 1 or 2 Family Dwelling-Number. drooms I Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use ___-___1 <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 1 '2 g �f El Town of 1A+t r.l O S c IL <br /> ID.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> L9'New 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 Newer Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ig'No----n-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(gpdst) 4u�t Dispersal Area Re ired(sf) Dispersal Area Proposed(sf) ` System Elevation <br /> if sc) O. L —7 S-a q3.S I 9S•d' 4'6.0' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer J J <br /> Gallons Gallons Units ° pp�.0 <br /> New Tanks Existing Tanks ,JDm, o V o .. 0 <br /> GO q v u <br /> t�V mi rn r=2-.T. 0, <br /> Septic naiel irg Tank / p oa /0 oa 1 <br /> CREST X <br /> Dosing Chamber , <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Si MP Number Business Phone Number <br /> JOHN E.RASMUSSEN 223-732 (608)635-4305 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ARLINGTON HARDWARE CO.,INC.,303 M• :• STREET,ARLINGTON,WI 53911 <br /> VIII County/Department Use Only <br /> A-Approved ❑Disapproved Permit Fee Date Issued Issutn eat Signature <br /> ❑ Owner Given Reason for Denial S 320. O© -/7- O8 ."'� <br /> IX.Conditions of Approval/Reasons for Disapproval I) <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 io size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />