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cC.,tDopartment <br /> Cornet eri.C,In, Sat t} aad B=!itd� D arn <br /> .e <br /> zUi iv.VJa hinotonPare nu&;zeta 13 U.Nrl�e <br /> Madison,P/I 531(x7 7162 S nt..y l s u w <br /> hnb,i(to b , <br /> fiiLd i <br /> of Commerce <br /> .__. St �tv -'sh i N <br /> In accordance with s.Comm.83 21(2),Wm Adm.Code,submission of this form to the appropriate goveannent d <br /> unit is required prior to obtaining a sanitary permit Note: Application £Dans for etate-owned POWTS are Projecl Address(if different thaw mailing address) f� <br /> submitted to the Department of Commerce. Personal information you vide may be used f secondary <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1)(m),Stats. aw`T73G Yf//�tv 4/G /7� <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 7 <br /> i(. ID61 6 Y&& SE. O 03G �. 40 / SOS <br /> �o �'� S p,✓ip (buts) L M pL5 AQ SS 4o7 003 otdovo <br /> Property Owner's Mai��ling Address Property Location <br /> 8Ef �S k,V ry l+w Gam a Govt.Lot 3 <br /> City,State Zip Code Phone Number /g '/a, Section �r <br /> /3YpeRlrl^ A-9MAI �,f Hyu 743--5'4G-5'X34 (circle one) <br /> IL Type of Building(check all that apply) T 40 N; R E or® <br /> PP Y) Lot g <br /> �y <br /> I[11 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block <br /> ❑Pubbe/Comemacisl-Describe Use ❑ City of <br /> 11 State Owned-Describe Use CSM Number ❑ villageof_ _ <br /> X,own of (AN(Oh ._ <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if applicable) _A. <br /> ❑New System k(Replaeement Seat= ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> VI.Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 im of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) D Pretreatment Device(explain)-_____ <br /> V.Dis ersaVfreahncut Area Information: - <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> Sia . S 90 p 900 /• 3 <br /> VI.Tank Info Capacity in Total H of Manufacturer <br /> Gallons Gallons Units a o $ ra <br /> New Tanks Existing Tanks w <br /> Septic vHolding Tank <br /> /deo <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plana <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /7- o��SFS his=X66-v�! 7 <br /> Plumber's Address(Sneet,City,Stalq Zip Code) <br /> )77C, 0 !Sl 3S vv� st�r� liter S�f�9 3 <br /> VI I.CDun /De t rtment Use Only <br /> Approved ❑Disapproved PermrtFee Date Issued Issuing A t gnature <br /> s 2 Jam" 9 27 20// <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plain for the system and submit to the County only on paper not less than 812 all inches in size <br /> SBD-6399(R.01/07)Valid thin,01/09 <br />