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aorramer�t;.�/d ��n> S f ri and Building,D,isicr c, t <br /> 'tin Gi G a ningion Avc Y O iso_71oa 4CNA tt <br /> �s'consin Ddadev,n,PR 53,07-7162 S.,vu ylw-rz�tgNumber(u, lill:n <br /> ®apartment of Commerce 55 1 L / Q <br /> S-9alitiary t'ermil f pplie;igUl a, <br /> In accordance with s.Comm.83.21(2),Wes.Adm.Code,submission of this from to th-appeojn'iate c c-evnentd 1131 7583 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Addrcs's(if different than moiling ad�h'ese) <br /> submitted to the Department of Commerce. Personal information you rovide may be used for secondary <br /> causes in accordance with the Pivaa Law,s.15.04(1)(m),Slats. /� <br /> I. Application Information-Please Print All Information &;ezI ( '.iy t0a <br /> Property Owner's Name Parcel <br /> 5vrlshioe (,olxkmlolum- MIX5 Alta Q 1f& 07-020-0-q'0169- 4-516.75'oi4X0 <br /> Property Owner's Mailing Address // �I�/ Property Location <br /> 9(O/ 111_`/� e a AtGovt Let <br /> City,Stale Zip Code Phone Number <br /> 'rk <br /> / tYe, Section 14- <br /> 9 q �1110 (circle one) <br /> II.Type of Building(check all that apply) T 40 N; R /6 *or W <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms 9Unit5 I!)� Subdivision Name <br /> �- <br /> �/ ,/ Block u <br /> p PublidComeercial-Describe Use e!0nWyMrprVwi <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑0,--,Village of <br /> 5(fown of_ QAIC�aThd <br /> IDL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System tKeplaccament System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Chan_ee of Plumbs[ ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑Noa-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound 124 in.of suitable soil 561ound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dhs ersat"Treatment Area Information- <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(at) System Elevafion <br /> /350411 +*] %70 <br /> VL Tank Info e�Capacity in Total #of Manufacturer ee11 L 95 tel <br /> Gallons Gallons Units <br /> New Tanks Existing Tucks w h <br /> Septics Holding TaN; �50 <br /> Dosing Chamber3$$0 4 1 5KAUJ ✓ <br /> /z D — 125p I S I SKANJ V <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prior) Plumber's Signature MP/MPRS Number Business Phone Number <br /> �21G1L /�0 .�//ryf �� /" t of-SF1SI 7il=S'GG—�t/3'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 S�e(f53 <br /> VIIL Com /De artrnent Use Ont <br /> Approved ❑DisapprovedPermit Fee Date Issued Issuin g egnature <br /> a �7`c�j 7' <br /> E01Owner Given Reason for Denial /�J�kf7 <br /> LY.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plane for the system and submit to the County only on paper out less than 8l z 11 irwhes in size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />