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} ut11vl l u V <br /> • <br /> a <br /> O heck ii1LLyoss 1 b AT p 02 7 511 <br /> commerCE Tr!ov MAY 5 At:.of / li:oildings Division Court <br /> t • S. tr.W n.. .in Ave.,P.O.Box 71.62 €cn L <br /> s c o fl s i I_I Ma icon, 1 53707--7162 Sanitary Permit Number(to be Filled in by Co.) <br /> Department of rkamtrwercepublic earl MD ,51 7 9 73 <br /> ' <br /> E , on el I-111'1-- ' State Transaction Number <br /> Sat , • - ermi • pp cation <br /> Jn 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 moiling address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> Purposes in accordance with the Privacy Laws.15.04(lxm),State. <br /> I. Application Information—Please Print All Information Cta'''se" AS ._ <br /> Property Owner's Name Parcel 0 <br /> TO)1 el 54arrT_Y .eftz. barn., - :mini✓ _e•got. - ,7-32--, 060- 4 <br /> Property Owner's Mailing Addicts propeity Location <br /> _ail? c Govt Lot _ �7 <br /> City.State Zip Code Phone Ntnober _ y,, M iv i%, Section F"3 <br /> CS2a PIQ4 i' `��Q (circle one) <br /> � \� .� . T g .N; R EorW <br /> IL Type of Building(cheek all that ap // Let <br /> �1or2Famil_y Dwelling-Number of Be moms Z -, .SubdivisionName <br /> • <br /> \..__ --/ Block# _ <br /> ❑Public/Commercial-Describe Use <br /> -.-- ❑City of <br /> ❑State Owned•-Describe list CSM Number ❑Village.of -- <br /> • ®Town of ✓3}txck....,,EactrA <br /> 140 Ik''c y <br /> V <br /> III-Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A. r, New System ❑Replacement System ❑Treatment/Holding Tank Replacement On]} <br /> 0 Other Modification to Frosting 5yatem(explain) <br /> "— List Previous Permit Number and Date Issued 1 <br /> .13• ❑permit Renewal ❑Permit Revision ❑Change of Plumber ❑Perot Transfer to New <br /> Before Expiration Owner ,_ <br /> IV.Type of POWTS Systerri/Component/Deviice:SCheck all that apply) .-• <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound r 24 in.of suitable soil ❑Mound<24 in.cif suitable soil <br /> 0 Heath=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> - <br /> Design Flow(gpd) ! Design Soil Application Rate(gpdsf) Dispersal Area Required(s() Dispersal Area Proposed(sf) System Elevation <br /> 6 or I r co v /sea .ze,o,A- q> r$- - g,, ' <br /> VI.Tan k Info Capacity is Total #of Manufacturer <br /> 2. <br /> Gallons Gallons Units m v U-� <br /> .3 <br /> Naw Teaks E sing Tanks u c s, � <br /> a U in H m W U A.+ <br /> •-3ettie cc Holding Tae 17.11•4 /Ain d X <br /> Dotting Chamber , _ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown oa the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/NPRS Number Business Phone Number <br /> _KtStKcf_, rte,ei'ee i'cq — A2.1lYv 407- .P`il- e7-it <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7-3(F, t -DG,Nr1 ; r.. &fi Ta"'& Lk)x s se>a . <br /> vim.Court -/De artment Use Only ..� <br /> PermitFeee Date Issued issuing Agent 5i` <br /> pproved ❑Disapproved 3 3 a0,r 5 J(o/a0 tie V"❑Owmer ner Gi Given Reason for Denial <br /> IX.Conditions of Appraval/Reasons for Disapproval <br /> mes ah to complete plans for the system anti sianeit to the County nail an paler DPI 1rcc thou 91,7?11 inches bit stir. <br /> SDP-(398(R.01/07)Valid thru 01/09 <br />