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nn t - .,✓r .i L <br /> Itr.• <br /> °I; ` UPI 3 0 2008 ;;. C1' e4( -1-I� 1-12,31.P.1 D13LD ,77575 <br /> 1i.; LI j commerce4,41A- c�v Safety and Buildings Division Coun <br /> 14 201 W.Washington Ave.,P.O. Box 7162 hone_ <br /> ` ' 't1lA ' Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> �,/ 578 05-6 <br /> Sanitary Permit Application <br /> State Transaction Number �gr7iz <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental <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 J/ <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. acia l ooli ,o Rol. <br /> I. Application Information—Please Print All Information (/ / _ <br /> Property Owner's Name R n Parcel# <br /> JCL,Rv1kik li-e 114 Jjv:ike 06ZON 8Ng60 <br /> Property Owner's Mailing Address Property Location <br /> P.o g71 6-65 AP Govt.Lot <br /> City,State ilk) Zip Code Phone Number T /Y� v., 5 . y,, Section Z <br /> t!Ake .h1�l15 I,t)� 5 56;! 710-?g?- 77 -4- /_ (circ one) <br /> T 6 N; R / 0.rW <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling—Number of Bedrooms II Subdivision Name <br /> Block# <br /> Public/Commercial—Describe Use 5)oraa p <br /> /l `/ P ❑city of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> f`(,Iy g Town of Chriy1le,fric, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. a New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification fcaon to Existing System(explain) <br /> • <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 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.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 13, <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units D o ° � <br /> New Tanks Existing Tanks ti c v ` y u A A <br /> y� a U H v) 'c. U F. <br /> S.peiver Holding Tank 200 201:0 l I Dc'i j m-ia,' , A. <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) Plumber's Signature fQP/MPRS Number Business Phone Number <br /> Se/IK.y T by N ht-t-?-2 _ ?2 ?? �.0-y8�- 7.c6 7 <br /> Plumber's Addfess(Street,City,State,Zip Code) <br /> P0, &X 56 L19f1P 114/4, W '5365/ <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Q Iss/uin Age Sign re <br /> �� <br /> Approved ❑ Disapproved Given $ 320-- - 7-q. V _ r�� ���'I( C 71-e-14C- <br /> IX. ❑ Owner Given Reason for Denial V <br /> IX.Conditions of A pprovval/Reasonss for Disapproval <br /> --- . E i°04/11 "440(40<-14(7 / i'1' ,/ <br /> --- Dt/2 AP/T9l/E° #4 M1 AJ VAS* E /7( -01Af - 7;1•AI : RE-Q tAKM <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 irz x 1 I inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />