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cOmm6fcP.wi-gov Safety and Buildings Division Coun l Z <br /> 201 W. Washington Ave., P.O. Box 7162 QYn B <br /> tL <br /> consinMadison, W1 53707-7162 Sanitary Permit Number(to be filled in by Copartment of Commerce /- <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 --l ' , <br /> unit is required prior to obtaining a sanitary permit. Note. Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> suhmined to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. 7 C� <br /> I. Application Information-Please Print All Information J 101 gs ��• L-G'Ko/k <br /> �Pn tm Owner's Name Parcel# ^ <br /> a 4 arc ,?,m&LetD3�- S31 rot /'/o U I <br /> Property Owners Mailing Address Property Location <br /> 7/33 All-4-4(,r 7)1- Got Let/ <br /> C t).State Zip Code Phone Number <br /> /., Section �3 <br /> _ <br /> I• �LL�� l� Yl J��� �Sl (OY ��v77� [,' (Circleoe of Building _it[ W <br /> II.Type g(check all that apply) Lot# <br /> I or 2 Family 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 <br /> V 110 7 IqI W' -Town of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑ TreatmenUHold ing Tank Replacement Only El Other Modification to Existing System(explain) <br /> N. ❑ 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 /> )(Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable sod ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dis ersa[/Treatment Area Information: <br /> Inst n Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sty System Elevation <br /> apo ' 7 S'S_-7 900 9y <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units $ u <br /> New Tanks Existing Tanks c m m <br /> o <br /> e`S <br /> tph Holding Tank N 5.0 / / �I�SQ� X_ <br /> Dosing Chamber l� _ll� 4)s/ <br /> V 11. Responsibility Statement- 1,the undersigne ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(Pf�int - Plu tier's Signature MP/MPRS Number Business Phone Number <br /> /VrovS /C.oevpwr <br /> Plumbers Address(Street,C t State,Zip Code) / <br /> W�IS- iE cl2�) 5' / <br /> VI11.County/Department Use Only <br /> .Approved ❑ Disapproved Permit Pee Date Issued Issuing A t S store <br /> ❑ Owner Given Reason for Denial 3 �� /40 07 <br /> 1\.Conditions of Approval/Reasons for Disapproval <br /> .Vtach to complete plans for the system and submit to the County only on paper not less than aux x It inches in size <br />