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• <br /> "sr _P)It t r)52,-1. 0-14-ot gMSLeo <br /> commerce.w[.yoV Safety and Buildings Division County <br /> ^^„ 201 W.Washington Ave.,P.O.Box 7162 Dare <br /> S C V■ ■$1 f Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 7 8 O g.3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <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 <br /> purposes in accordance with the Privacy Law,s.15.04(IXm),Stats. 1\..bra <br /> I. Application Information-Please Print All Information tl <br /> Property Owner's Name <br /> l f:'/S1:141,1 --n r G i i '' .: 1' Yom Parcel# G!,^ <br /> E► c s At)c.:(0.. Si�)u- G�o Tcr(c1 Ne J 0709- a,t- <br /> Property Owner's Mailing Address '-- Property Location <br /> 2 5L 4YY1 'Dv. Govt.Lot <br /> City,State Zip Code Phone Number Se Y., WE '/., Section 6 <br /> (circle one) <br /> t inn rJ3 $°� T �] N; R B E orW <br /> II.Type (check all that apply) Lot# <br /> 4 1 3 Subdivision Name <br /> if or 2 Family Dwelling-Number of Bedrooms 'T <br /> Buck-#. S.rSe-4 " er Estates <br /> ❑Public/Commercial-Describe Use • - ❑City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use <br /> F/Town of 141.44 lerISI1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. @ New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <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 t Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) <br /> ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd)' Design Soil Ap Ilion Rate(gpdsf) I Dispersal Area Required(sf) 1 Dispersal Area Proposed(sf) I System ys e Elevation,lC t <br /> LACO I 1 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> V U <br /> Gallons Gallons Units V 72 <br /> New Tanks Existing Tanks P.0 in w tn u.C a. <br /> Septic or[te4di,R Tank 1206 120 - ( MEAD K I <br /> I t... x <br /> Dosing Chamber ` ) t� <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 -MP/MPRS Number Business Phone Number <br /> 16 •00avv w. Me i rroYL- .---4=0e_. L.t) � 22 )165 '3t.€5103 Plumber's Address(Street,City,State,Zip Code) U <br /> (OSt 3 CA-k- 4 ak. vAak,t.e) 14% 555,3-7 <br /> ~VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Age, -•_a ature <br /> Approved ❑Disapproved i Ory <br /> ❑Owner Given Reason for Denial S��(St 6 I `o \ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x"1 i es in si l. - 9 •2008 .J <br /> SBD-6398(R.01/07)Valid thru 01/09 Public Health MDC <br /> Environmental Health <br />