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-A * 455.9 ' tots hi,is 4'/ <br /> comores.wr.g <br /> m ov Safely—and Blandings D vision - S 1' <br /> 201 W.Washington Ave.,P.O.Box 7162 .A bJ '' t Ii [ <br /> t O n Madison,WI 53707-71.62 Unitary Permit Number(to be filled inbyCa) <br /> 517999 --- <br /> Sanitary Permit Application State Transaction Number <br /> in agnardarce with s.Comm.tt3.21(2),Wpe.MM.Co*lalbrtusaion of this form to the appropriate governmental <br /> unit is recited prior to obtaining a ssnitery pernhlt. Note: Application forms for stataowned POWTS are Project Address(if different than mailing address+) <br /> submitted to the Department of Commerce. Personal information yno provide may be used for secondary i, 1%..)(.0.) LANs E _p. <br /> !..,.1.•. in axardanCa with the Privacy Law,a.13.04(1xm),Stag. <br /> L u, 1 - .on Idformatioa-Please Print MI Information <br /> Property Owner's Name. Pagel# <br /> 00aAk.-D uErre 1 b`1 , .— 3L2 r k7t `-a <br /> Property Owner's Mailing Address Property Location <br /> 10 DdI taR...lA.2 Lr,-1- . <br /> City,State Zip Code Phone Number _ 1/4., A.i I"-j yy Section 3 4 <br /> 5(>10 PRt \"t lit - i 1 535- tc9)4ers-r o as- T N' j! <br /> a Type of Building(check all that apply) Lot# <br /> 1 2 Family Dwelling-Number of a:drvoam .3 Sulbdivision Name <br /> 1_Ai.'O u-+4P(j.ft .x <br /> Block# <br /> D"<[ideoa+me trial-Describe Use ❑c,ty of <br /> 0 State Owned-Describe use • CSM Number 0 Village of <br /> ei 03L Town of 012-t 5.rb t-- <br /> IIL Type of Permit (Check only one bar oft Tine A. Complete-lilt-El—dap- pdcabie) <br /> C]New System 0 Replacement System ' I Other Modification to Existing System(explain) <br /> Permit N D,at�e Irsmple�d <br /> El <br /> ❑Pamir Renewal ❑Pertloit Revision 0 Change of Plumber ❑Permit Transfer to New 05 U 1 ^Vb he <br /> Before Expiation Owner -- <br /> ,,, �, e,. ,m„ . ■ ■ oe: , - . • <br /> l.91 on-heaturized In-Ground 0 Pressurized In-Ground 0 At grade 0 Mound 24 in.of suitable soil ❑Mould<2.4 in.of suitable soil <br /> ❑lidding Tank 0 Other Dispersal Component(explain). _ 0 Pretreatment Device(explain) <br /> V.Dls, .•l/Treetment Area Information: ..A <br /> D..*.F Design Soil Application Rate(Ltpdat) Disper9 ken R red(f htporPol�ed(elf SYsrem 1 <br /> • _ , am <br /> 3 <br /> Capacity in Total d of Manufac�er d <br /> -. I Gallons Gallons Units "' <br /> e -- v�r New Tanks Existing Tanks g i <br /> (Sirs A .O <br /> Peptic mhloldinrrenh k 2°151D /� A1,'If -- A`I �■_la III <br /> YIL ' , + P , , ' Statement-I,tie •: , - , re+pmmibfty tier iasiollodon of the • a ' ' ., oil the!!!ached plain. <br /> bee Name(Aaet) tom` ." Number Business Phone Number <br /> lii&jr4rill ,6- Zee i_ a` 2,2'1 - ' b <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PAv._ Je7a S ikuvAALtoC b Ma", O 22W KlLC-°51` PO 1j V14-AptItv v I 1 .53713 <br /> - VIII Coanty/Department Use Only i <br /> owed Permit Fee Date . ed issuing • <br /> f <br /> mil/ <br /> �� <br /> 0 Owner Given Reason for Denial r /,esisg r. el 7.! <br /> IX.Condit .f Approval/Reasons for pis.pp �„e, •, r= Ago"4232 <br /> . a( • <br /> Attach to complete plens tor the fyatem wad while to the County rely en paper net tem thew d 1a a 1l Indus in size -- - <br /> SBD-6398(R..01107)Valid thru 01/09 <br />