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e0171171erce.w4gov Safety and Buildings Division <br /> I cowry <br /> {•�s i 201 W.Washington Ave.,P.O.Box 7162 <br /> D.sp.�.o f 1oS li t 1 Mad sonmninsarcia, ,W1 53707-7162 S �u r/Je <br /> ' anitary Permit Number(to be filled in by Co.) <br /> Sanitary permit ATi177r^p�� -5-3 z z cL3 \JJ <br /> In accordance with a.Comm.93.2](2),Wis.Adm.Code,submusfou Application State Transaction Number <br /> unit is requhed prior to obtaining a /707yl8 <br /> submitted to the De 9 nmtary permit Note: Appti tion forms for sfats-owned PO molental Side �J$/S2f <br /> Department t of Commerce. - Personal information you provide may gove <br /> U ses c accordance with the Privacy Y be -ad for secondary Project Address(if different than mailing address) <br /> I� q lication Information_ Law t.15.04 I m Stats. <br /> Please Print All Information <br /> Property Owner's Name // __ <br /> D NQ,sp're a-14/(t <br /> I Fk%1E—T-crr�btza.;,w -�' .' Parcel <br /> s <br /> Property Owner' Mailing Address <br /> Zoo o• ox 93z oto—y323—oL�F3o <br /> OAK Property Location <br /> City,State ear - SEiIIfVdEerM N A) <br /> Phone Nr <br /> Zip Code 2 Govt Lot �o <br /> _ umbe <br /> MMNX'S2T _ (�� $HOzs ��' �. Section Z3 <br /> lI.Type of Building(check all that apply) _ <br /> Lot# T_Vp N, R�E°nW <br /> �J I ort Family Dwelling-Number ofBedrooms_�� <br /> 3 Subdivision Name <br /> G Pubhc/Commercial-Describe Use Block# - <br /> CState Owned-Describe Use ❑city of <br /> CSM Number ❑ Village of <br /> III.Type of PermU <br /> Permit: (Check only one box on line A. Complete lice B[f IpDp(ic, JZTown Of Q—'q <br /> A <br /> IQ New System, ❑ Replacement S stem _ - - <br /> Y ❑Treatmentq-Iolding Tank Replacement Ord <br /> Y Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal <br /> Before,Fx Permit Revision Change otPlumber <br /> pvation ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> T e of POWYS S stem/Com onent/Device: Check all that a 1 Owner <br /> Non-Pressurized In-Ground ❑Pressurized In- <br /> Groundplain Mound 24 in.ofsunable oil❑gt-Grede <br /> ❑ � s <br /> ❑ Holding Tank Other Dispersal Component(explain) 0 Mound<24 in of suitable soil <br /> V,Dis ersaVrreatment Ar ea Information: OPrauwunent Devia(explain) <br /> Design Flow(Bpd) Design Soil Application Ra <br /> pP te(Bpdst) Dispersal Area Requved(,f) <br /> NT Tank Info Dispersal Area Proposed(at) System Elevation <br /> �� <br /> Capacity in Total <br /> 11 1113 - #0f Manufacturer- <br /> N..Tucks sting Tanks Units <br /> Exi <br /> $epjc or V 8 _ <br /> Dosing Chunber . 6 J3 <br /> (►00 PJO S/lJ4tJ �RRT/T/ <br /> Y'll.Responsibility Statement- I,the undlraiga ,assume responsibil or installation of the POWYS shown on the attached plans. <br /> Plurygr"M <br /> 81 EXCAVATION <br /> P m ignature <br /> M&R C MP/MPRS Number Business Phone Number <br /> Plum pp <br /> ° e ..G <br /> VIII. Coon a artment se of <br /> Approved 0 Disapproved Permit Fee. <br /> Date Issued Issuin Age i cure <br /> IX. Conditions,f pprovavl/ReaonsforDuaRon for Denil <br /> $ (" 2g <br /> pproval „J <br /> A[tsch[o complete plans for the system and submit b tM1e Cozen[ <br /> Y only on Asper not Iw IM1an B L3 x 11 inchn In size <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />