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commerceml.gov <br /> Safety <br /> Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 _..—.. <br /> isoon si n Madison,W1 53707 7162 Sanitary Permit Numbcr(to be filled in by Co.) <br /> pttperlment of Commerce O --- - - <br /> —"'- —- - State Transaction Number <br /> Sanitary Permit Application 56 zSGa <br /> rnmental <br /> In accordance with s.Com83.21(2),Wis.Adm.Code,submission of this form to the appropriate gave <br /> m. — - <br /> permit. Vote: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> mi[ is required prior to obtaining a sanitary <br /> submitted to the Department of Commerce. Personal information you provide may be used far secondary <br /> u oscs in accordance with the Privac Law,s. 15.04 1 (m,Stats, --- �2 7 953 zone doe A_p_�, <br /> I. A lication Information-Please Print All Information — Parcel q <br /> Property Owner's Name _,./. <br /> Property Location <br /> Property Owner's Mailing Address � <br /> GG ah.J /005 a,� 4e- �tl— Govt.Lot__J_ 91 <br /> City,State Zip Code Phone Number y,, V, Section <br /> ^ ((/) / J,circle one) <br /> 0110 <br /> Lotti <br /> If.Type Of Building(Check all that apply) St odivision Namc, <br /> I or 2 Family Dwelling-Number of Bedrooms, _.— <br /> Block — --- --- <br /> ❑Public/Commercial--Describe Usc— __. _. -.--- — ❑ City of—_-._ — ----- --- <br /> -'---N-- -- ❑ Village o - <br /> CSM umber f - -'- —' <br /> Q� Kr�J .J <br /> Ll State Owned- Describe Use <br /> _ P 173 -- — <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement.Tys[em ❑"Calmenl/IfoldingTank Replacement Only r[lothcr,Modification to Existing System(explain)- <br /> — <br /> _ __—_ <br /> ___ -- _._--.--- -- List Previous Permit Numbcr and Date Issue <br /> R. ❑ Permit Renewal ❑Pemtil o'crumt ❑ Chant <br /> hangs of Plumber ❑Pcmtit Transfer to Ncw <br /> IGwner <br /> Before Expiration <br /> � - <br /> 1V.'C a of POWTS S stem/ComponentlDevtce: (Check all that apply) _. _. _ -_ - - - - <br /> __- <br /> ❑Non-Pressurized 1n-Ground [I Pressurized In Ground Ll At-Grade El Mound 24 ioof suitable .it <br /> Mound 24 in of suitable sod <br /> ❑Prctmamuent Device(explain)_ -- <br /> Holding Tank Ll other Dispersal Component(explain)-_ -___ <br /> V.Dis ersal/'Creatment Area Information: _ — --- System Elevation <br /> d Desi n Soil Application Ratc(gpdst) Dispersal Arca Required(sQ Dispersal Arca Proposed(sf) y'`� <br /> Design Flow(gp ) g PP �� <br /> .-7 0 <br /> Capacity in Total R of - — -- Mamd'acturcr u e u ^ <br /> o <br /> I.Tank Info Gallons Gallons Units W H a � <br /> New Tanks Existing T.nks y U y � <br /> $apYc.xe Holding Tank3____------- —_ ---_ <br /> Dosing Chamber <br /> VI 1.Responsibility Statement- 1,the undersigned,assume responsibility,for installation of the POW'UMP/MPRS Numbwn on the eached Business Phone Number <br /> Plumber's Name(Print) r Plumber's Src / ,�� <br /> --?a769/ .:3 9 --or—lJ-- <br /> Plumber's Address(Street,City,Slate,Zip Code)t ��7� <br /> _ <br /> VIII.Count /Dttpar[ment Use Only --- --- -pale Issued - jl%suing age gnaNrc <br /> Permit Pec <br /> KApproved ❑ <br /> Disapproved 4 <br /> C, <br /> pp L 3.J) 9 2 Du_ __ -- <br /> ❑Owner Given Reason for Denial _._ - -- <br /> IX. {�Conditions of Approval/Reason.-..stun-x- -I <br /> '( ��UE �boawf 6Gcvaf,.ok oa Y35Q <br /> I1old(hg TevIIC Ma,K61t_ R1,11111ro be e� yr <br /> MSL. ( Yclfoad "*4 R>;E fS 933.o Jlo? g0jultirf ilia 6s A6we 933.0 srs�� <br /> Attach to complete plam for the system and submit to the County only on paper not less than a lit x 11 inches in size <br /> SB13-6398(R.01/07)Valid flint 01/09 <br />