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ON COMPUTEwSCANNED <br /> c <br /> .W1aw Safcty and 8WIdings Dividion <br /> 201 W.Washington Avc.,P.O.Box 7162 �L1 J21y1 <br /> 4tous�TO;OMMAM4 <br /> s i n Madison.WI 53 707-7 1 62 Sanitary Permit Number(to be filled in by Co.) <br /> _ 498 4,4'1 <br /> Sanitary Permit Applicatio State Transaction Number <br /> In 3CCord3noC with 5.Contm.83.2t(2),Wis.Adm,Code,submiseton or ring corm to tilt nppropriax govtmm t 13 8 3(p 7z <br /> unit is required prior to ubwiaing a sanitary permie Nate: Application forms for state-owned POWTS arc Project Address(if different than moiling uddrebs) <br /> submitted to the Department of Commerce. Personal information you provide stay be used for secondary <br /> .rs in:oar nlanco with the Privacy Law.e_15.04f 1)(m).Stars, <br /> 1. APPLication Information-Please Print All Information <br /> Property Owner's Name Parcel N <br /> L` K ibL-, 0-Ai1 lPt:)Zui�6 (kt,6bauL )4lta � C'.aic ns6- 5 jig q - (D)-Le)n, <br /> Property Owudr'n Mailing Addrtaie Prorwrty Location <br /> Ph. aL k �6 Govt.Lot <br /> City,Staie Zip Code Phone 1/ <br /> Number . r:, Section <br /> bilLs e i0t S400q _ 76-755 21 Li z�l 1y cCit'lCon <br /> II.Type of Building(deceit ail that apply) Lot�) T N; [2 E ot(9 <br /> ❑1 or 2 Family Dwelling-Number of Bedfooms Subdivision Nainc <br /> Block# <br /> �PubliciConMioecial-Describe Use <br /> ❑City of <br /> ❑Suite Owned-t?esLribe Use CSbf Number n Villuge of <br /> e TUwn of L- <br /> 111.Type of Permit- (f.�h#+tk only nne hoe nn line A. Complete line B if applicable) <br /> A. <br /> �4r:w System ❑Replacement System ❑TroJtmont/}iotdutg Tank Replacement Only ❑Ot)xr Modification to Existing System(explain) <br /> B. ❑Porntit Renewal ❑PCrmitRevisioo ❑Change of'Plumber ❑1'urmit Tr3nsfet'to New List Previous PCrmit Number a�Y)elC Issued <br /> Before Expitution Owtior <br /> IV.Type of PO WTS S stem/Cutn uuesat/Deviee: Check all that apply) <br /> .WNun-Prw%uized In-Ground ❑Preasurized In-Ground ❑At-Grade ❑Mound 24 in.of suitable ioi) [3 Mound<24 in.ofsuimble soil z <br /> ❑1loldiug Tank ❑Otha r Diepeaiul CoMponout(ozplttin) ❑Ptrtrcaeneut Device(e><pluin) <br /> V.Die enaUTreatment Area Information: <br /> De/si�gn Flow,(gpd) Dceign Soil-A7pplicution)(atc(brydso )ispersa/i Area Acquired(at) Dispce{nnl Amu Proptna(ifj Symcm Elevation c 7 <br /> CL77� a / q t 1 75 �L 94 ' / L <br /> VI.Tank Into Capacity,in Total #of Manufacturer <br /> Gallons Cwllons L'nits , ro R <br /> New Tanks Exi3liu•7enki E <br /> Sepiic or Holding Tunk 'S/�C, �. E V I <br /> Docint ClumbeT <br /> VII.Responsibility Statement-f,the andaraigned,aasunsa mpousibittty for bnsta atWis of the POWTS show hC attached plena. <br /> Plumbof i Natne(PrUtq C SY::, <br /> MP weber Aasin m T`hotta Number <br /> -T rP �L%y_ 24 Z 7I5 7S6-.ZQ 1 <br /> PI bcr's Addirso(Street.City.Slate.Zip Code) <br /> U. If.�51-C%fi- sS1 b K VA 5 �0 <br /> VQL Countyl1R artment Ute Only <br /> �Apptoved ❑Disapproval Pcmuz Fee Daate Issspuped Issuing,Aj{ wM <br /> -3 Owner G f /tr Niven Reeson for Odiial ' � � I ( t07 <br /> IX.Cunditions of ApprovaUlteasona for Disapproval <br /> Anrch to complete clans for the systco eod sabtait to tht County only on parmr nut ka than a l!2 s I I inches in slzc <br /> SBD-6398 M 01107)Valid thni W/O <br /> Z0/Z0 39Vd XVd ONINOZ N-10d 9t7Z6S8V9TL OT:ST L00Z/Z0/i0 <br />