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CCEQW <br /> !!I tea # . 1, c�.� 42..,$ao <br /> co-.- <br /> ommert:Q.wi Safe •and f zags Division County ' <br /> JUL -201 v2i fe:-hinR ie P,O.Box 7162 vim <br /> tscons Madison, i3707-71 62 Sanitary Permit Number(to bbeefilledinbyCo.) <br /> Deportment of Commero�, 37 80 J 7 <br /> F't}bfiC i! State Transaction Number <br /> Sa>n�t.ary �l�trn� 'tt$tlOill 4.7176q In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental "OW/ '� <br /> unit i$ required prior to obtaining a sanitary permit, Note: Application forms for state-owned POWTS are Project Address(if different than mailing a dress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> u.••sesini accordance with the Privac Law s. 15.041 m Stets. jy�� ry f <br /> I. A�plichtion information-Please Print All Information R five <br /> Property Otvncr's Name Parcel ti <br /> Rc, 0. , ......4■11 . A. LLC Rob_ Tam 06IZa t-igLi &r <br /> Property Owner's Mailing Address Property Location <br /> 't hm2 5, r. /47 Govt.Lot <br /> Ciry,,,fate Zip Code Phone Number -} rrs� Ng" y,, y, Section Z <br /> CAWt��'9). __7JZ Cro�g-4.1 - L VU (circ one) <br /> TI.Type orBu Iding(check all that apply) Colo T �+ N; R E r w <br /> PP Y).( <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block 4 <br /> X Public/Commercial-Describe Use L.in1Ouifjt Ctrs/ice( --- <br /> ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use - <br /> R Town of— .11 fr* <br /> IIT.Typo of Permit: (Check only one box an line A. Complete line B if applicnble) <br /> A. KNuw System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumher ❑Permit Transfer to Now List Peevioue Permit Number and Date Issued <br /> Before Expiration Owner 1 i <br /> IV.Type of POWTS System/Component/Device: (Check nil that apply <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.orsuitablesoil 0 Mound<24 in.of suitable soil <br /> AL Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/TreatmentArea Information: <br /> Design Flow(Bpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Ares Proposed CO System Elevation 61 n <br /> VI.Tank Info Capacity in Total 4 of Manufacturer u <br /> Gallons Gallons Units A <br /> New Tanks Existing Tanks w 4 Li v <br /> $ .o r Holding Tank — . /I'A Da/ A ( <br /> Dm ins;Chamber <br /> VU.Responsibility Statement-i,the undersigned,assume responsibility for installation of the POWTS shown an the attached plans. <br /> Plumber's Name(Print) ' Plumber's Signature = •/MPRS Number Business Phone Number <br /> i ePPY'f . ' et rg- `Irte) All. 711.5?.Z 240-1 7s-z7 <br /> Plumber's A rots(Street,City,State,Zip Code) 1 f . <br /> P a 8c..i, 60 Loki Aleg, bua 5 4:5_L r <br /> VIII.Coun fDe.artment Use Ord <br /> w Permit Fee Date issued lssul. . igna c <br /> pproved ❑ Disapproved "J p <br /> ❑ Owner Given Reason for Denial S 32o "1-q-o / ../ ,/V ` ►'- _ <br /> TX.Conditions of Approval/Reasons for Disapproval <br /> - 5E� ea W S /1AI/A& 641—Pl. <br /> - Q'At Oii Zt eg t- kA4Pre f>-e-OrKG ie If /12E-T N l02$1.1 <br /> Attach to complete pions mar the system and tubmtt to the County only on paper not less than it to a 1 t Inches in Size <br /> 513D-6398(R.01/07)Valid thru 01/09 <br />