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COlilmerce.Wl.gov Safety and Buildings Division County "--- <br /> 201 W.Washington Ave., CO. Box 7162 1 N-7 <br /> isconsin Madinon,W153707-71(12 Sanila�YPermitNumbe'r(to •filledinbyCo.) <br /> Departmerd of Commerce ./ /io6 7 <br /> transaction Permit Application State 'r`ansacction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code.submission of this form to the appropriate govemmcntal __V_ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(ifdi@rent tan maihngaddress) <br /> submitted to the Department of Commerce. Personal information you provide ay cc <br /> Iw used for sondary <br /> purposes im <br /> n accordance with the Privacy Law,s.15.040)(m),Stats. <br /> 1. Application Information-Please Print All Information ,��� D AVE <br /> Property Owners Na e ^ Parcel N 0/R92Z 7$00 <br /> I 7 <br /> 07-M- . •/ 4('07/000 <br /> Prop ny Owner's Mailing Address Property Location <br /> c r ee k Gavt.I,m <br /> City,Slate f Zip Code Phone Number �-- - <br /> '., S Ilion � �} <br /> GJ 34024— 3S7_O 6.3 / (ca, <br /> c lemic) W <br /> t f�q&_ N: RFS I!olo . <br /> Il.'Type of Building(cheek all that apply) Lot N <br /> Imo. _. _. . . 3 - - � <br /> tutor 21'amily Dwelling-Number of Bedrooms Subdivision Namc / <br /> —� <br /> Block ft -/lame- r <br /> ❑Public'Cam uncial Describe U.c -.. <br /> City of__. <br /> ❑Stale Owned Describe UseCSM h'wnbcr ❑ Village of <br /> *1 own of'_ T'4"._.. _S Cl <br /> III.Type of Permit: (Check only one box on line A. Complete line 13 if applicable) <br /> A. �Q�4 — <br /> F'\M System ❑ Rcph,ccmrnt System ❑ 'l'a+aimmtit/Tlolding"I'ank Roplaecmcnt Chdy ❑ Other Modification to Exii ling System(explain) <br /> 13. ❑Permit Renewal ❑ Pemlil Revisionred Date List Previous Permit Number !.sued --- <br /> ❑ change ofPlumbq' ❑Permit'I'r;mxlerla Nmv <br /> Before Expiration pwnn <br /> sIV.'T o <br /> ef POWTS System/Com onent(Device: Check all that apply) <br /> ,I., Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound_24 in.ol'suitable.,,it ❑ Mound 24 in.nl'suitabl soil <br /> ❑ (folding Tank ❑OtherDispersal Component(explam) _ ❑Pretreatment Device(explain)_- <br /> V.Dis ersalffmattnent Area Information: <br /> Design flow(gpd) Design Soil Application Rale(gpdsl) Dkpcnal Area Required(xt) Dispersal Arca Proposed(st) System Rte iation -- <br /> 3C o , 7 709 <br /> VI.'Tank Into Capacity in 'fetal it of Ni.emlactm'er <br /> Gallons Gallons Unm, v o '$ u <br /> New Tanks [ixuting'1'anks u o R 3 v .o A <br /> r� U y h i4V <br /> Septic or in.�,ik 751 <br /> G <br /> Dosing Chamher --- <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW'I'S shown all Phu allarherl plans. <br /> Plumber'.Name(print) Plumbcr s Signature b4P/MPRS Number Busines. Phone Number <br /> e5 LA y — ,2F Ag' <br /> Plumber's Address(Street,City,State,Zip Codc) <br /> o;'_s—1 _-5 i r'e—,J I.J F <br /> VIII.Coun /Dc arlment Use Only <br /> Approve) ❑ Disapproved Permit Pee Datc Issued Issuing A ' nature <br /> qq` e <br /> El Owner Given Reason for Denial S O 5o D <br /> IX.Conditions of Approval/Reasons for Disapproval -- <br /> Allnrh to mmplele prom for Ile system and suhnJl to the County Indy on paper not lea than 81a s II Inehas in size <br /> SBD-6398(R.01+07)Valid that 01/09 <br />