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commerce.Wl.goV Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Wisconsin Madison,WI 53707-7162 Sanitary Pe mit Number(lo be filled in by Co) <br /> eparlrneM of Commsros 210&7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental '%T_ Vv <br /> unit is required pridr to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Prejcct Address(ifdifferentthantnailmgaddress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 1 nn11 <br /> eHl2scs in accordance with the Privacy Law,a.15.04 1 m Stats. ,?82)9 f01($sh K08et, <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> /4)X' Yss �t#� s daS 111.2 q o9 LSO <br /> Property Owner's Mailing Address <br /> Z,j9 SOX goiu_ tc) k4nc Property Location <br /> FVEQGkfl.A) Co 30t439 Govt.Lot <br /> City,State Zip Code Phone <br /> Phone Number -_y, Section <br /> /rW/� (j� �O� T �(0 circle one) <br /> Type of Building N; R E or� <br /> yp g(check aid that apply) Lot# <br /> Yl or 2 Fanuly Dwelling-Number of Bedrooms '( Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of C <br /> Town of JG� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System $Re lacement System Y p y ❑TreatmenNHolding Tank Replacement Only C1 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer b New i <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arca Required(sf) Dispersal Area Purposed(sf) Syshm Elevation <br /> © `55`5 B s <br /> 191 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ge $ <br /> New Tanks Existing Turks e Q O V v g <br /> pL GosA�ro 6V in 0 LZ (D a <br /> oc r Holding Tank v7U <br /> Dosing Chamber J <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plane. <br /> Plumber's Name(Print) Plum is Signamm MP(MPRS Number Business Phone Number <br /> 117 /5 5�6 q 74 <br /> Plum 's Addres�stmet,City,State,Zip Code) <br /> D X /60 E LC lS,F <br /> VII .'Coua /De artment Use Only <br /> Approved ❑Disapproved Permit <br /> Fee Date Issued r Iss g ent Signature <br /> ❑Owner Given Reason for Denial trilit/ ZYOYie 0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Anach to complete plans for the system and submit to the County only an paper not las than 8 In z 11 inches In size <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />