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`i v)_17,_ pr 1 .`��,--t Industry Services Division County'i z\ ; t 1400 E Washington Ave j'�(,�,L, AA d l^
<br /> y� .': ;s �}. car t, �, f` ,r� '' Box 7162 • Sanitary Permit Number(to be filled in by Co.)
<br /> - 10 i i t,i( lair.; ! P.O.ri�fl,sa;.Box 7162 •1b2
<br /> E.' J.-F7,,.,...c ?�, �• State Transaction Number
<br /> 17� Y't A lication
<br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit
<br /> is cimi c_pror tot'-c-',ai3 c.i fcm.ir_Note:Application forms o..ia ke ti,. aiPOINTS.are submitted to Project ed•>_,-•=,(if di`Prem tbs. mailing address)
<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.
<br /> 1. Application Information—Please Print AU Information •,
<br /> Property Om is Name Parcel# 7t� ���0 O
<br /> 0t� /t,1 -� I.trC--s vii ( • b .08
<br /> Property Owner's Mail' g Address - U Property Location
<br /> 1_ �� Govt.Lot
<br /> �de Phone Number t ,
<br /> City,Sta. Zip ^,C. /3,f4 U /, Section-
<br /> V 6)7 T N> R �V h or FV
<br /> H.Type of Building(check all that apply) Lot#
<br /> 1 or 2 Family Dwelling—Number of Bedrooms 2f Subdivision Name
<br /> Block#
<br /> ❑Public/Commercial—Describe Use ❑City of
<br /> CSM Number ❑Village of
<br /> ❑State Owned—Describe Use Ill ik TI)
<br /> i1Ji J ys,� c�'r
<br /> -1 Town of i"�
<br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. t ew System LI Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> r't i ❑Cltaugef p
<br /> nt:,! bar ❑Pcrmst Tri f_:,ton,,,,,,,
<br /> List Previous Permit Number and Date Issued
<br /> E. U Permit Renewal f u Perr 1r Revision
<br /> • �. Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground •❑At-Grade L!` ound>24 in.of suitable soil 0 Mound<24 in.of suitable soil, r
<br /> ❑Holding Tank ❑-Other Dispersal Component(explain) " --retrcaunent Deviee(explain) 6-'.L`' P- -- 1 11 A
<br /> -V.Dispersal/Treatment Area Information: l+�v
<br /> Design Flow(gpd) Design.Soil Application RRt gilds Dispersal Area7R�equir d(sO Dispes sal eaq Proposed(sf) System-Elevation ti n w,e,,�
<br /> B �vr I'CAAPtt✓ (Z0.(o—
<br /> 1000 �. n,= tc 2.x•1 z-ctl 3�ast cctt ,9a
<br /> Capacity in i i"A5!//1 Total Rot- ivisrmfactu er
<br /> VI.Tank Info
<br /> Gallons G 3 Gallons Units
<br /> 61C • '*`�•-q -. B o re is
<br /> N• ew Tanks Existing Tanks t U inti &I w w p.,
<br /> Septic er Holding.Tik 1 1 U f"L-° I li ,I
<br /> .s,v. k
<br /> Dosing Chamber to q DU
<br /> VII.Responsibility State ent- I,the undersigned,assume„1•esponsibiiity for installation of the POWT CiVin on MPRS the attached Business ore Number
<br /> Pln he's Name(Print) I Plumber', stare ,
<br /> Plumbers Address(Sire City,State,Z)p Code)
<br /> tkik.,? . k. "(, 1 ' -*IP ,s if- .
<br /> VIII. t part let t.Use Only .:,i- i f._::I=- o'dn>�/=' I tit=_ suets : Ii'$umgAgentSignaturePer unit Fee ;Dif Approved ❑Disapproved S 1 i 3 0 - ib' ': EA--• - /—--„ �..'t� 1 —.._:____cj:)
<br /> - ”n>._.___ mile#j r 11 Ck �- .G /15 ref-tec€d D� pae-4
<br /> I�,GondititiSs trfApprtiY�llllgauns{oz �ppruval Qp___
<br /> Protect & Maintain: 0 Mound / ❑ At-Grade site and 15'-feet downslope in-its-tlatural ; tl tri•
<br /> condition. No compaction, excavation, disturlbai;ce, or vehicular traffic allowed. 3`b cal
<br /> c al ,e.
<br /> .; to r,iu.,!,ea Ft!ns for the syekem Aid submit to the.Connty only on paper not less 8 tri x it incheYtn size 1 1- r G log
<br /> rEnsure tank locations are within 150'to all-weather service pad and within 15'vertical depth a 610,414p,
<br /> , s-_-__hi,
<br /> difference to all-weather service pad-Specific servicing mechanics must be provided if exceeded. Tee
<br /> SBD 6398{I;.08/14) •
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