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.=L.DIN( LND ECEI1dE IF , <br /> iv <br /> commerce. t+ cj ety . RI t]dings Division County k <br /> iti <br /> r IL MA'' 2 &OY�as Ave.,P.O.Box 7162 <br /> Oa y1�, <br /> ISCO t'1 Madi•.n; ` 53707-7162 Sanitary Permit l r.....>'--r,..r,=.qnori in by Co.) <br /> Department of Co mer 517933 <br /> PI tbi 1-lanith MnC <br /> San State Transaction Number <br /> :,1; t., .P:- •.n <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(1)(m),Stats. <br /> I. Application Information-Please Print All Information C.'- lJui K 19 <br /> Property Owner's Name Parcel 4 <br /> Just,iv t r- ,- Hu.ell ner 0;o-0707-0C ( - 5Y.2 - O <br /> Property Owner's Mailing Address p Q 60x 20 2. Property Location <br /> '= it /lc % _ Govt.Lot <br /> City,State �/ Zip Code Phone Number ig r. 1/4 /1JE. t/., Section �p <br /> Qa!T y�4rl� �� Sys (circle one) <br /> H.Type ofBuilding(check all that apply) Lot 4 T N; R 7 E or W <br /> IIC or 2 Family Dwelling-Number of Bedro- Subdivision Name <br /> Block 4 -� <br /> ❑Public/Commercial-Describe Use — ❑ City of <br /> ❑State Owned-Describe Use • CSM Number ❑ Village of D <br /> Oil Town of Gto 55 �p i tr in s <br /> /0& 60 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> IN New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing.System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber U Permit Transfer to New List Previous Permit Number and Date Issued <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 /> 60o t .S /za0 4200 '( .C) t <br /> VI.Tank Info Capacity in Total 4 of Manufacturer l <br /> i <br /> Gallons Gallons Units o <br /> New Tanks_ Existing Tanks I o a, , +,, Ci w r <br /> 0 <br /> a U rn � yr i=U C.. <br /> Septic or Holding Tank /2.-S-Cs I /2i)6 I 74 Pel di 8 ,y/ <br /> Dosing Chamber I /_ 5-0 6 5-v i AL iar I trC I I <br /> lP �P <br /> VII.Responsibility Statement-I,the undersigns. assume re po. 'bility f.• . allation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) : u .- .1 MP/MFRS Number Business Phone Number <br /> - 'q »( <br /> Plumber's Address(Street,City;State, ip Code) -"."."'"7 <br /> ?-3 i -DarA : ( t esbeAArc__ Lk)_r_ -�e>7 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agen - e <br /> gpproved ❑ Disapproved $ Q /'�� - <br /> ❑ Owner Given Reason for Denial 783 .' 312a I c 8 ' r r t. <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 1re a 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />