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• <br /> `!✓ .9..I tif, C!_t' <br /> �"; ty , <br /> cGirimerce wt},9ov )l ,stet, eshm 301di e.,P.O.Box 7162 <br /> i; <br /> 'scoM$diSt�dt; 53707-7162 <br /> Dreporbnant or samitzu Permit— Number(to be filled M bY Co.) <br /> is 'C: . ' .. �. ---— i <br /> hi accordance with s.Comm.8321(2),Wis.Adm.Code,submission of this form to the appropriate governmerdal <br /> unit is required prior to obtaining a writers,permit. Note; Application forma for state-owned POWTS are __________________ <br /> submitted to the Depot:meat of Commerce. Personal information you px'ovide my be used for secondary <br /> /Imposes in accordance withthe Privacy Law,o.15.D4(11fm),Strata <br /> X. App on Information-Please Print All Information <br /> Property Owner's Name <br /> J C -‘) sE, ..,E N d I e K EvA. _ i _ r <br /> Propety Owner's Mailing Address Pioyerty Location <br /> S01I ..,S0HP5 Cr- <br /> City,State Zip Code Phone Number <br /> 114 a- blot , wt _3s7z iC o )7iq -) Zog <br /> II.Type of Building(check all that apply) -Lot# / i <br /> 1 1 2 Family Dwelling Number of T Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ----- ■ City of <br /> CSM Number ■ <br /> 0 State Owned-Desenbe Use i • <br /> IIL Type of Permit (Check only one hot on line A. Complete line B if applicable) <br /> . A- &1 f&System 0 Replacement System D Tresonem/Holding Tank Replacement Only ❑Other Modification to Fisting System(explain) <br /> List Previous Permit Number text Date issued R. ❑Permit Renewal D Permit Revision U Chmgt of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS Sysyson/Camponent/Devicm (Check all 0 apply) -—. <br /> ❑Non-Presemized In-Groond 0 Prs ed In-Giouad 0 At-Grade f'1tound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> Q Holding Tank ❑Other Dispersal component(explain) ❑pretreatsnent Device(e )— <br /> V, r. . rsaVFreatment Area Infotmaidon: Elevation <br /> Design Flow(gpd) Design Soil Appiicatiod Rate(gpdat) Dispersal Area Required Of) Dispersal Area Proposed(af) System Elevation <br /> 6 Dc4 0-L / oar /s737-5 , /H./ <br /> Total IF of faetwor o <br /> VI XankIdo C in i <br /> Canons Gallon lhmta ro q <br /> New Tanks 8 B <br /> Taub 1 C0 x 3e;D 1 <br /> sepeeia Teak 1 2 S .1 /a. r2 5T X <br /> Datives member if 00 —.-- ' 57 o. / <br /> Cdaa sT- <br /> VII.Responsibility Statement-I.the nodersigned,assume resptosibnity ror inotallittlon of the POWI'S shown ant dm attached pins. <br /> 's Name(Print) Plumber's Sigcature MP/MPRS Number Business Phone Number <br /> plaatbertdresa(Street,city,sere,Zip cone` r/ ST iCiAlc (--, ,,e,Ch) (..,0--r sas <br /> ---ci&- <br /> VIII Conntylbepartment Vse <br /> ❑ �� Permit Fee D../ Date Issued ? IsmiinB Agsnt t r"1 Y' <br /> � ❑owner Given Reason for Derainl t t,:`" .—.. ---' <br /> IX Conditions of Apprvd ils for Disapproval <br /> S'C e 0 v �r m( G-E/ E-(r n:w <br /> v4- -II -7oo3 Off. ?-0 ISSur_ -ZP. rh_ vJILL. <br /> �- CJ� �-� TU 2c L iG �f rZ iC=O E vJ r n4 !/J S Thu cr b/..) S <br /> �0 (,,E�.�(Z �TU PL u 1--(r_. .' t:n --- 0,,�, >J=.2 �c1 �j� <br /> Attacb.to em.plets pions for the system and a.�itte t Comtg only or piper not kss kb=11112>i 1l Whet In Ass <br /> • a13-3,Z5$a 0_111‹.- $a4I9 RevLevJ ,n")' y Pe---zfLi( r <br /> SHL)66398(R,0]107)Valid flats 01/09 C1 14^4 a`7 a g_Y1>,u"d rZ , DIZMJ <br /> -f <br /> 0-} -/I -7_000 <br />