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- --- <br /> cr�l-ram�rt;-1~vve.r�nuv e.- ty and Build, D kr,ien ,,i <br /> tnepsa <br /> e nAve YU CoxIIU'LW. VJashineto�' Madison,PA 53767 7163rtm nt�+of Comgmerce <br /> �e'�SI➢$�IY'y i�'g'�'�hI' Set C 2 tact tN <br /> In accordance with s.Colum,83.21(2),Wis.Adm.Code submission of this form to the appropriate go mini ntal <br /> unit is required prior tel obtaining a sanitary permit. Note: Application fortes for state-owned POWTS are Project Address(if different than mailing addroae) f t, <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance ith the Privacy Law,I.15.04(I)(m),Slats. / <br /> I. Application hlfor ation-Please Print All Information G �L'A✓ .f/0y Ro U I <br /> Property Owner's Name <br /> ����//�� r Parcel#OT 0/x-x•50-/.S, f:,r <br /> /"7r4Hi N I!/'77(8I /S - /00 - e olrio000 <br /> Property Owner's Mail <br /> m Address Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number S <br /> Yq Y., Section <br /> NoYik9, ,to(' �N SSOS7 (osl rfy9 9904 (c"vcleone) <br /> IL Type of Buildin T 40 N; R /S E o <br /> YP g(�Iteck all that apply) /) Lot# <br /> .�1 or 2 Family Dwellin Number of Bedrooms O' IS— Subdivision Name <br /> Block# �p <br /> ❑Pubbc/Comm acial-Describe Use <br /> ❑ City of <br /> El State Owned-Describp Use CSM Number ❑/Villageof 1 <br /> Ly'town of �,/aG_kJo vt <br /> WofPerniiit:it: ( eck only one box on line A. Complete line B if applicable)tem ❑Replacement System ❑Treatment/Holdine Tank Re lacementOnly p ❑ Other Modification to Existing System(explain) <br /> enew.) ❑P__,Revision ❑ Change of Plumber sevousPermitNumber and Date Issued <br /> ❑Permit Transfer to Newiration ii� TS stem/Com --'/Device: (Check aB that. 1 ) <br /> NeNon-Press mized Tn-Gr:and ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.ofs citable soil <br /> ❑Holding Tani: ❑0t cr Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaUTmatm t Area Information: _ <br /> Design Flow(gpd) D ign Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 3o0 . '7 4-0,! 9 `573d e <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ='• c <br /> ew Tanks ExtlfingTacks <br /> Septic or Holding Tank 00 <br /> Dosing Chamber �'0� s�/�k/ �� <br /> VII.Responsibility St Cement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature n MP/bB RS Numbe Business Phone Number <br /> /2/t/c / off''✓c/.�J / .t�lo/ a�J s-s�s. �r.J- <br /> Plumber's Address(Street/City,State,Zip Code) <br /> 7760.(/,. ' 3S We5s7`Y <br /> Will.Comb /De in Use OW <br /> 1d Approved El Disapproved Permit F. Date Issued Issuin A (Signature <br /> ❑ Owner Given Reason For Denial S�/�iJ <br /> IX.Conditions of Appfoval/Remons for Disapproval <br /> Attach to complete plans for the system and submh to the Courtly only an paper not less than a r/1..,ow size <br /> { 6 i .• 4 u,.d <br /> SBD-6398(R.01/07)Valid thin 01/09 <br /> 'ZONINEY <br />