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• APR 1 1 .1 u: Check To 395�� UBi 'AV <br /> commerce. afcty an dings Division County <br /> 201 W.Washi ton Mc.,P.O.Box 7162 • 0,rW-' <br /> S e o n S i n Pu tic Health ,WI :3707-7162 Sanitary Pcrmit Number(to be filled in by Co.) <br /> Department of Cotsrnorca Envi nmental Health 51 9 L.} <br /> Sanitary Permit Application <br /> State TransactionNumbcr� <br /> P <br /> In accordancc with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to thc appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for statc-owncd POWTS arc Project Address(if different than mailing address) <br /> submitted to thc Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. ���'� �1� �� - <br /> I. Application Information-Plcasc Print All Information <br /> Property Owncr's Namc R' e r 11- (sue YO i Parcel# <br /> / /`o)-e-e- 14sse'n e(--t) 0'309 -02 9,2 — 8000 G <br /> uProper�ty Owner's Mailing Address Property Location <br /> (� o10 I-h0h WCcvl I 0 3 Govt.Lot <br /> City,State Zip Codc Phone Number /0 g, v.. /WA) yti Scction o�9 • <br /> (Dct rw w,-• 6-3 6.a g y 1- 593 7 (circle one) •. <br /> II.Type of Build 1 ing(check all that apply) Lot q T 9 N; R E or W <br /> Al or2 Family Dwclling-Numberof Bedrooms A 7 I Subdivision Namc <br /> _" Block If <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Usc CSM Number ❑Village of • <br /> p(o pos f c Town of U i C.✓ r — <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) . • <br /> A. ANew System y ❑ Replacement System ❑Treatment/flolding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑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.ofsuitablc soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Dcvicc(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsl) Dispersal Area Required(s1) Dispersal Area Proposed(s1) System Elevation <br /> UC.) „ .5 j•Zvt-) i o20 io 88.(1 se. iff.c <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units o o'a u <br /> v � <br /> New Tanks Existing Tanks u g .2 u B 2 2 <br /> n.U in « h A. <br /> t7 A.. <br /> Septic or holding Tank /.Z 8 c 1.2-J 6 2 __Alec,.L€. <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation id the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature Ivii'/MI'RS Number Business Phone Number <br /> /-arm d-✓e-..: (.�•) - H•e.+n(,../2. . -•J2 Li.. .c. /6,s e:>6 - 8 3/-b o 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (6 9, 3 CTN " I(..,. LAJ(..r.,_el c162--k- L.), s'3S7 <br /> VIII.County/Department Usc Only <br /> pprovcd ❑ Disapproved <br /> Permit Fcc Date Issued lssui gent Signaturc <br /> 4- 14-0$ � � • <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Rcasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 3 in s 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />