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• I e1< TO S'3q 0 n e n ., -Pt:27 <br /> commerc•:Iii 4 71/.J N 2 2 ,,$afet�it uildings Division County! <br /> it ( j Was n Ave.,P.O.Box 7162 <br /> 'C�O 1 Mai icon, ' 1 53707-7162 Saniiaary Permit Number(to be filled in by Co.) <br /> Department of m !'ublic ealth MDC ' 517 q C3 <br /> Sa • b-.!!!a• J ": 5i • on 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(l)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> / �� US ��'3Z�l`ti70 <br /> /roperty Owner's ailing Address Property Location <br /> ! l 7 /. <br /> [� �� �/ Govt.Lot <br /> City,State . ...de Phone Number 44/-- y, ,47/%, Section f 2 <br /> 1/ <br /> 5i �l/!? - ( l (circle one) <br /> T 12 N; R /2_ aW <br /> II.'Pype of Building(check all that apply) Lot 4 n <br /> Or-for 2 Family Dwelling-Number of Bedrooms // Subdivision Name <br /> 1 Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use _ <br /> i 't i 94Town of ff-- 'zi.," <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> A New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. `❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑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 ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �� _ u `/7 //7< //76 9/> <br /> VI.Tank Info Capacity in Total 8 of Manufacturer <br /> Gallons Gallons Units .o :.-2 o v N v <br /> New Tanks Existing Tanks o .2 2. -0 m <br /> a U Do A rn `t7 <br /> Septic or bolding Tank / �_ <br /> /C'C/U /ce%r% ./2-4-1 ,-"--/ <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) �l s ignature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only r <br /> Approved I ❑ Disapproved Permit Fee Date Issued 4�r.-:St :atir <br /> ❑Owner Given Reason for Denial 31, '/- i�/Og «,�:��,[e y.,_, <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> uu <br /> I <br /> 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x It inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />