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/!/ <br /> 7G31.ko it o?nsot.o GI1..it y,753 <br /> commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Cl rG <br /> 'sco fl$j fl Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of commerce 5/8 O. O <br /> Sanitary Permit Application State Transaction Nuriuber <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(1Xm),Stats. �r�t id� Din I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Enc 4ist l 0'108" U=71-4004-15--C>Property Owner's Mailing Address Property Location <br /> 5004 CY._ _yt5A-t(2( 12a. Govt.Lot <br /> City,State � �� Zip Code Phone Number 5g y., NE %,Section <br /> (circle one) <br /> Cress :PIAthSi W1 53528 T 7 N; R 8 Eee-W <br /> I1.Type of Building(check all that apply) Lot# <br /> ^/ 5 Subdivision Name <br /> (t!1 or 2 Family Dwelling-Number of Bedrooms <br /> Blpck-U, 5.trsei ridge ES-ta:v <br /> ❑Public/Commercial-Describe Use ❑City of <br /> . CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> litTown of Mt elel te- 1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' EYNew 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 /> l <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Ili/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 /> ( .4 1500 1512 eet 6I— 570" <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units „, t i.)New Tanks Existing Tanks ° S g E . m <br /> o.U y so w U <br /> n• <br /> • <br /> � <br /> tic arl'Iplding Tank eat .-- 12 l M E , X <br /> Dosing Chamber 1 - <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature -MP/MPRS Number Business Phone Number <br /> Anot rcw W. M€,rlAolc I _ - i 2201x5 33 L No 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> fof',l3 (}+- r ■auna-k12.t , IN 53551 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Ag . =•% •1 <br /> id-Approved ❑Disapproved S 2' �) <br /> to/l/ /0 d <br /> ❑Owner Given Reason for Denial .....71-4-'' t „ R t <br /> IX.Conditions of Approval/Reasons for Disapproval D L )w v <br /> JUN - 0 2008 ,J <br /> Attach to complete plans for the system and submit to the County only on paper not i ss that 8 IA a 11 inches in sire .• <br /> Pu blic Health MDC <br /> Environmental Health <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> • <br />