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■ <br /> s .' . r • V D JECEIWE —DC5#4 g3'7ffi <br /> Is <br /> • COmme ' , i -govt U� 5 Saft t Buildings Division 'caoney y\—" ^—" <br /> �D7�f,u J.ton Ave.,P.O.Box 7162. <br /> IS CO ?J Nu <br /> '� I Madison WI 53707-71 b?. Ssni[ery Permit Number(to be filled In by Co,) <br /> Department - <br /> S .7'.Tirl;;r I nr,. -trait ,-E� v41 ion SalleTranssetionNumber <br /> -- <br /> In aceordante with s,Comm.83.21(2),Wis.Adm.Code.submission of this forth to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Afplioation forms for atate-owned POWTS are Project Address(if different than mailing address) <br /> submined to the Department of Commerce, Persona' information you provide may be used for secondary <br /> purposes in aeeerdenee with the Priva9 Law.s, 15.04(1)(m),SlLV, <br /> 1. Application information-Please Print All information _ _ <br /> Props Owner's Name Parcel Parcel it <br /> U 1- car L* t J r k c u ` - D1 I I — 't•,1 - o 3-6) <br /> Property Owner's Mailing MacreSS , • Property Location <br /> I0 (bVa-%ivi v.%.A Oovt.lot <br /> Ciry,Stare Zip Code ^Phone Number 5'iiij yti k y, Sect„ f 4; <br /> 1 11 P.e\).Ar 5'3`13.2 (cir one) <br /> T CI N; It I E W <br /> II.Type of Building(check all that apply) Lot It <br /> tl 3 or 2 Family Dwelling-Number Of t3edrpgnt SubdivLvo Name <br /> Block N -- --- W'f'1 31 L 0 '`cap (C q t h IN) 40 i <br /> ❑Public/Cummertial-Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> Ili Tows of.gri$ ,I_ <br /> •'III.T r mitt eck only one box on lint A. Complete line B if applicable) <br /> A raRiNew System ❑Replacement System U rear trrlent/Holding Tank Replacement Only • ❑Other Modification to Existing System(explain) <br /> List D. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Previous Permit Number and Date Issued <br /> Before Expiration .i Owner --. <br /> 1V,Type of POWTS System/Component/Device: (Checlt3tst1 ply) ..-- . <br /> ❑Non-Pressurized In-Ground 0 Pressttrized In-Grater At-Grade Mound?24 in-of suitable soil ❑Mound<24 in-of suitable soil <br /> ❑holding Tank 0 Other Dispersal Component(rap! ' ) ❑Preveatrnent Dv (explain <br /> V.Disp ersaVTreatmen t A tea Information: <br /> Design Flaw(gpd) •Design Soil Ayplicntion Rate(gpdsl) Dispersal Area Required(s() Dispersal Area Proposed(sf) System Elevation <br /> C� <br /> tooO o v4 1r};...1 ,a° m lb'.s. " <br /> VI.Tank Info Copaciry in Total P of Manufacturer <br /> Gallons Gallons Units ti <br /> u N <br /> New Tanits Existing 7snks 0.3 y x t5 a <br /> , r Holding Tank u IvM <br /> i 2o° , -� I <br /> DosingChrobcr 7D0 WAS <br /> 1. <br /> VII,jtesporisibility Statement-1,the undersigned,assume respanslbillty for installation oflne 1'c1WT5 . own on the attached p'ian5. <br /> Plumber's Name(Print) : PRS Nummber Business PhontNumbcr <br /> r,e..t� W�'• • 2ZG WIZ, 910 .b23-`16 I <br /> Plumber's Address 5treel,Ciry,.isle,Zip Code t <br /> P 0 5 4(0 ia � �/ - .5-37"- <br /> V1i).Coun /De•arlment Use Onl �� <br /> r�� •• ❑ Disapproved <br /> Permit Fec p•1 - e. Issuing A: �'±� <br /> S <br /> ❑ Owner Given Reason for Denial /-. + U f�_� '; . <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> L - <br /> 1tn sea to complete plans Far the system and submit to the County Only as Only nor lnr akin ITrr 111.helm In star - <br /> SBD-63911(R. • <br /> 03/07)Valid ihru 01/09 ' <br /> • <br />