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commerce:Wi.gov Safety and Buildings Division County y .. <br /> ,y <br /> 201 W.Washington Ave.,P.O.Box 7162 QI-A. L- 1 <br /> 'S'CO n t+ Permit Number(If be filled m by Co.) <br /> Department of Commerce <br /> C-�- <br /> Sanitary Permit Application Stat ran//sactionNumber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Ov,t—1 �(/r ea <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(i//f different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Za82.1 !tw KtI.v DO� • <br /> purposes in accordance with the Priv Law,s. 15.04 1 m Stats. OA- <br /> I. A licatiov Information-Please Print All Information <br /> Property Owner's Name Parcel# 07-03'(-2'$r�B-z�-S <br /> 3k"59 3815-7ars.D• 4. <br /> Property Owner's Mailing Address /043 r uLh d A Owe Property Location <br /> 7", + Sal + -Tt• /'1 GovL Lot '} "J <br /> City,State Zip Code Phone Number , , <br /> t 5Q � /., /., Section Z <br /> a u U. j-,7'j 0a(circle one) <br /> /IL Type of Building(check all that apply) Lot# T 3-7 N; R I U E or W <br /> 04 ort Family Dwelling-Number of Bedrooms 2- 7 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> El State Number El Village of Sta[e Owned-Describe Use —� e <br /> Val. 1 9l �.rnwn of )ft--d o R K <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) - _ _ <br /> A. ❑New System 19Re li cement System <br /> ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision El change of Plumber <br /> ❑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 /> ❑Non-Pressurized hl-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in of suitable soil ❑Mound<24 in..of suitable soil <br /> IFL33olding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.D's ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(id) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units d ii v v <br /> New Tanks Existing Tanks y°-y° <br /> 0 <br /> Septic Holdivg T k JrOO /�R w <br /> Dosing Chamber 1 <br /> V11.Responsibility Statement-I,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> 1 ber's Name(Pr' t) Plumber's Signature MP Number Business Phone Number <br /> cIc It awKiMr � rPs, _ 2-2-2-874 `f7Z--LVL/ <br /> tier's Address(Street,City,State,Zip Code) <br /> Z /J-O f' Jt.1-. lc u c rk l v �T 1853 <br /> VIIL County/Department Use Onl <br /> Approved ❑Disapproved Permit Fee Date IsW,s�,ueed Issuing Agent e <br /> ❑ Owner Given Reason for Denial S 3 ! 5-� 8 &kI <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Tow-tts 56D -106-7 1 <br /> Attach to complete plans for the system and submit to the county only on paper not less than 8 M s I I inches in size <br />