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<br /> . [' G E JV Industry Services Division County
<br /> J` 1400 E Washington Ave J -
<br /> x/i•. ^t�C�1,�)D , 1 P.O.Box 7162 • Sanitary Permit Number(to be filled in by Co.)
<br /> V;I \_So I fH fl 2021 'oil 517.^.7_714^1
<br /> Wp/All 1\ , [nLc .. L•,` ,•:!iii1_
<br /> • State Transaction Number
<br /> Ma�'t pSa ttta `F ' „t Application
<br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit
<br /> - -- o C)W-T'•a ,ittedto - Ar�.(tiff,li feree.t!h rimnilingaddress)
<br /> ._r,.-. .:,ter rr.::::ter::::^•c i',c,-,;;:;_-_;-;-.;.. '- h:..:x a ::....d...-.......S- ..c., t,kn .._ -- - --
<br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �j' 1,,, ,g,,,....,
<br /> I. Application Information-Please Print All Information J
<br /> Property Owner's Name Parcel#
<br /> '..-1-,�:1„� v� V 02-9-/6 /Z -763 . Yo�•�
<br /> Props Owner's Mailing Address V Property Location
<br /> ZZ. k )e i vim. Govt.Lot
<br /> City State r, I Zip Code Phone Number kI y, 54.1 /a' , Section Z'2.46-
<br /> DQ-Ze 2l cp 141-r-- I e1353( T t N, R �2Z..( rW
<br /> II.
<br /> Type of Building(check all that apply) Lot# LI'
<br /> 1 or 2 Family Dwelling-Number of Bedrooms / Subdivision Name
<br /> Block#
<br /> ❑Public/Commercial-Describe Use ❑City of
<br /> ❑State Owned-Describe Use CSM Number 0 Village of` 221 ]�„- r I ca
<br /> l ((Town of I�-r J`�-p1.
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 1
<br /> A' New System 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> ( r,_ • n ._ „r - I I--! c.,:, , first t nre: List Previous Pertnit Number and Date Issued
<br /> t.J rctu:ii fl.LW ia: i u _ — -- I . ..... ..-'•---------- I
<br /> • y I Before Expiration' •v � �V••V•Vy - �.•.VV•••.-W--Je- i Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> on-Pressurized In-Ground ❑Pressurized-In-Ground '❑At-Grade 0 Mound>-24 in.of suitable soil ❑Mound<24 in.of suitable soil
<br /> • LJ Pretreatment Devies(explain)IJ Holding Tank ❑Other Dispersal Component(explain)
<br /> "'V.Dispersal/Treatment Area Information:
<br /> Design Flow
<br /> (gpDesign SoiAppliication Rate(gpdsf) Dispersal Area Required
<br /> (st) Dispersal Proposed(sf) Systemat n
<br /> • I
<br /> J��d) Soil
<br /> LAreal�le
<br /> ••
<br /> I
<br /> VI.Tank Info Capacity in -Total , : e: . .
<br /> I I- Gallons Gallons Units o w y
<br /> New Tanks Existing Tanks 4. 0 B113 '8 t
<br /> k U in . il.L7 P.
<br /> _or holding T.,:.k D
<br /> Dosing Chamber v .5J 6'5" I I I
<br /> Vll.Responsibility State eat-I,the undersigned,assume r nsibil[ty for installation of the POWTSPon the Numberched plans.
<br /> Business Phone Number
<br /> Plumber's Name(Print) I Plumber's S' y*re
<br /> ISVI.'Q,,,
<br /> Plumber's Address(Street,City, teC)Lip Code) /-) 7 53
<br /> ?2
<br /> Q � � ii.)),.14---_,5
<br /> EL _ situ/:cparel:LP.nt Jse Only _ T._ - r Cant ciut:Et,
<br /> ._...-_ - Permit Cee • Date-sem-.. _ _- -
<br /> El Approved 0 Disapproved 464.00 04/27/2021
<br /> ❑Owner Given Reason for Denial
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> ' Note: Property owner submitted land contract documentation to verify change of owner •
<br /> from Kenneth Weaver to Trina Winger.
<br /> Attacht,:amplete suns for the system and submit to the County only on paper not less than 8 r/2 x 11 inches in size
<br /> T: T. ' ?E-4-e5 . 202/— O Z TOS,
<br /> SBD-6398(R.08/14)
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