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i <br /> commerceml. ov <br /> 9 Saf,ty and Buildings Division County <br /> rAjbvjk,isconsin 201 W. astingtonAve.,P,O.Box7162 <br /> M ison,WI53707-7162 ural! " <br /> �atmrhamrn of Conunaree Sanitary anift Numbs(y be filled in by Co.) <br /> Sanitary Per it A n1 a `No a <br /> In accordance with a.Comm.83.21(2),Wia.Adm.Cod +� cation State Tran ction Number <br /> unit is required prior to obtaining a rani ,aubmissi a of form m the appropriate governmental '�— l <br /> submitted to the u"Y Permit Note: plica forms for stateowned POWTS are W <br /> Departmem of Commerce Paso 1 infomu n Y prm'ide ma Project Ad res(ifd$'erant than mailing address) <br /> ea m accordance with the Priv! Law,a.15,04(l m),Stan Y be used for secondary <br /> I. A Batton Information-Please <br /> Print Anati y) 3 <br /> Property Own—'e Name orm <br /> , Parcel M� .0/�•1•, •%'f S05.om <br /> Roperh Owna Ownsb Mailing Addrae l' <br /> 4AGr48a 4220403100 03J00° <br /> (gPO el& 3r l9ve. Property ..mt <br /> Cih,St,h <br /> P Code Phone Number Croom Lot <br /> fre(f r:G fn/� *3 — YS — Ys Section </ <br /> IL Type at Brrildutg(chedr all that apply)1 7rS" 47o4- V 76 <br /> Lot R T R / (tack one) <br /> 3 9 <br /> 1-2 Family Dwelling-Numbs ofBedroome <br /> Subdivision are le or® <br /> 0 Public/Commercial-Describe Use Block# <br /> 0 State Owned- ❑City of <br /> Describe Uee CSM Numbs <br /> 0 VBlageof <br /> ILL T 15Town of la F ller"e <br /> A ype of Pervrih (Chetckk only,one boa on lbre Com ere ' e B U appdcable) <br /> 0 New System Kv Replacement System ❑Tr 11 Idin <br /> g TaokReplaeemart Only ❑Other <br /> ration to Existing System(explain) <br /> B. ❑Permit Renewal <br /> ❑Pamit Revision of ben <br /> Before Expiration 0 Chang ❑Pemap Tramfer y New List Previous it Numb-aM Date yawed <br /> rv• eof POWTSS s6mdCom on Owaa <br /> (�Non- ent/1levice: Check tltst 1 <br /> Moo-pressurized <br /> lo-Ground w paeurized lr-Gro <br /> und ❑At- de 0 Mound>2t is <br /> ❑Holding Tank ❑OMa Dlapaeal Component(explain of euilabk soil ❑Mord< m.ofauitable soil <br /> V.Dig asaUT'reahnert Area Information: 0 PrebeamrentDevioe(explain) <br /> Daign Flow(9p- Deign Soil Application Ra <br /> td8pdet) DP e sl <br /> . s <br /> 300 Requned(af) Dispersal Area Proposed(at) System Elevation <br /> VL Tank 600 93,a( <br /> Gpacny a To N of <br /> New TMU Gallons <br /> Tank; Gallo a Unit, Mam4curer o G <br /> O V <br /> Septic a Holding TsnkGG .q t .a <br /> lloarg Clamber <br /> VIL R's Name lbty Statement-I the undersigned,ase me rmpo sibgi for installation Of'he POWTS shown on the attack <br /> Phwba'e Name(Print) <br /> Plumb-'a Sigmlure plans. <br /> kr n f MP/b/p S Numb- Bus lams Phone Nmnb- <br /> Plumba's Address(Street,City,Slate,Zip Code) a�.f1S/ 7/5-- ?6G—SVS <br /> Cow /De artnent Use Onl <br /> Approved 0 Disapproved itF. Doh t,eued <br /> $ Issum g Pmt= <br /> ❑Owner Given Reason for Denial 25 5 <br /> IX.Conditions of Approval/Reasons fa Disapproval 07 <br /> Atbehy complete pyre forth and sub,WWtjC-rad <br /> yonlywpp-notbm than 911 hes isah <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />