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5e ID ii 007,Z ati_re IId�16111P111 i
<br /> commerce. CI A� ,y III itrt�,.inB Division County
<br /> .. 1 201 W.Washi ton : c.,P.O.Box 7142 - �4-ri-a1
<br /> �•r, ,Y' ,WI 37077162 Sanitary#permitNuntber(to be Gilled in by Co.)
<br /> peporttttoen of Co orce PU+tic Health M' VI! r
<br /> >— -�.•• �^•J-- :• ye State Transaction Number
<br /> Sans -y 'ermit Application .
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<br /> In acConlance with s.Comm-83.Z t(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 thantttailing address)
<br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary la p 052.---to ,ses in accordance with the Privac La w S.15.04 1,m Suits /y5
<br /> I. Application Information-Please Print All Information — . 7
<br /> Property Owner's Name Parcel al
<br /> 1 ):11;ael. else , / ...-, . .-'// cfcs o o 40 8 - 3•5-Y 9�`3 4,-0
<br /> •
<br /> Property Owner's MaIlin Address �j Property Location •
<br /> 641017 /'r4�,51cQ 9"4:4A e}`' Govt.Lot �
<br /> City,State ! zip Code rPhonc Number S(.L y,. Se IA, Section
<br /> l�e..t t.n a.Ir e_ f t,;. Ji3 S�3 7 $.50 `I S Y 9 Nt R (circle one)W
<br /> ___.
<br /> II.Type of Building(cheek all that apply) Lot 0
<br /> jilt I or 2 Family Dwelling-Number of bedrooms Al - Subdivision Name / ,
<br /> block q ,JNe'311.$ r a AS Po-,ce-1
<br /> 1
<br /> 0 Public/Commercial-Describe Use City of
<br /> ❑State Owned-Describe Usc,
<br /> GSM Number Q Village of, '
<br /> iiiCr[own of� ' OLO
<br /> III.Type of Permit: (Cheek only one box on lint A. Complete line 13 if applicable) — - _Y
<br /> A, 0 New System , 'Replaccment System ❑Treatments bolding Tank Replacement Only 0 Other Modification to Gusting System(explain)
<br /> 13, 0 Permit Renewal ❑Permit Revision ❑Change of Plumber Q Permit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration Owner
<br /> IV.Type of POWTS Stem/Component/Device:,Check all that apply) ---,
<br /> ANon-Pressurized In-Ground ❑ Pressurised In-Ground 0 At-Grade 0 Mound 24 in.of suitable soil Q Mound<24 in.of suitable soil
<br /> O Holding Tank L3 Other Dispersal Cwiiponent(explain) - ❑Pretreatment Device(explain)
<br /> V.DispersanreatmcntArea Information:
<br /> Design glow(gpd) Design Soil Application Ratc(gpdsl) Dispersal Area Required(si Dispersal Area Proposed(sl) System Elevation r /
<br /> to 0 0 . -7 • 95-8 /Jay f38,3 es.o, 82-S-
<br /> ,
<br /> VI.Tank Info Capacity in Total N ofor Manufacturer o
<br /> Gallons Gallons Units °
<br /> u
<br /> f3ewTwnks E7tlringTanks o N 4.
<br /> ar U to VI V.0 Pa
<br /> Septitor Holding Tank ,,,°a et, z-ec - e4¢1---' )c
<br /> Doing Chamber 4,6-° �L7 / ,•,�
<br /> VU.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown en the attached plans.
<br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number
<br /> Al 01.4/64.0 W- Me 4 Aldo ,, '--)• WOO .P.r1 o es 468-I?)-VD 3
<br /> Plumber's Address(Street,City,State,Zip Code) IPP-
<br /> G S 13 G r 1-f "/4 .'" Wa.....at.../44-,— 4.5; .S3 y �
<br /> Vrrt.Coon /De artment Usc Onl
<br /> "pprovw 0 Disapproved Permit fee Date Issued I '-u,y;frf'_
<br /> r'7 •
<br /> ❑Owner Given Reason forDenia) �' ' " 1 ° - V41 ••
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> G V (T t. S 1 YV c trF - tar
<br /> Attach to complete pha ra for the system and submit to the County only on paper eel less than 8 In s II Incbe$in size
<br /> SBD-6398(R.01/07)Valid thru 01109
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