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cotTlrlteree.wl.gov Safety and Buildings Division County �p7 <br /> 201 W.Washington Ave.,P.O.Box 7162 84 r n I <br /> i s eo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Dapac of Commerce .503-72 <br /> Sanitary Permit Application State Tana on Numher <br /> // . <br /> In accordance with a.Comm.83.21(2),Wis.Adm Coda submission of[Itis form to the appropriate governmental tV Clad <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for ante-owned POWTS are Project Address(ifdit£erentthanmadingaddreas) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary �t�, <br /> purposes in accordance with the PrivacyLaw,a.15. l)(m),Slats. `3 799 /r11 h'r r {� <br /> I. Application Wm <br /> ormation—Please Print An Information <br /> VA G'/' U <br /> Property Owner's Name Parcel# <br /> 07—o?d^ i-4/-/6-36-a <br /> ,4,14A .r a ,Pa+Iv W i ly TVW94- a 02-0,0 0-oia dodo <br /> Property Owner's Mailing Address Property Location <br /> 3S! Crown Peed)' GovLLot I SSC-3S�' <br /> City,State Zip Code Phone Number AJULY, AILA)_Y., Section :76 <br /> GO/I'm 6 i k /y/p T 4/ N; R /6 (circle on L <br /> IL Type of Building(check all that apply) J Lot# <br /> &1 or 2 Family Dwelling—Number of Bedroomsy� Subdivision Name <br /> Block# <br /> ❑Public/Commerciat—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number 3915 2,4 ❑Village of <br /> V a,I P /X-1 ® Towaof SwIJ.S <br /> III Type of Permit: (Check only one box ort line A. Complete line B if applicable) <br /> A. ❑New System y kyReplacement System ❑Treatment/IIoldwg Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change List Previous Permit Number and Date Issued <br /> (.'bang ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Typeof POWTS S stem/Com onerat/Device: Check an that apply) <br /> I$Non-Presumed In-Ground ❑Prossudzed In-Ground ❑ Al-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis emaVrmatment Area Information: <br /> Desi l d) Design Soil Application Ratdgpdsf) Dispersal Area Required(31) Dispersal Area Proposed(at) System Elevation <br /> tic 5' 4aS 1 9;,.ao <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Galkno, Unita <br /> New Tanks Existing Tanks <br /> ow m rn i:C7 p. <br /> Septic or Holding Tmrk ��O 90(J / ..Se/!� L✓ <br /> Doaug Chamber <br /> VIL Resportsibilily Statement-I,the undersigned,assume responsibility for installation orthe POWTS shown w the attached plana <br /> Plumber's Name(Print) Plumber's Signature WINIPRS Number Business Phone Number <br /> IZIc% Alo le,A s <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 4776, 0 f/ �S We65 < ri Wr SyyS$ <br /> L Cam /De artment Use Oral <br /> Approved ❑Disapproved Permit Fee //���� hhDate Issued Ise ' Agent Signature <br /> ❑Owner Given Reason for Desist Sias nn VI-a�I p ) - <br /> IX.Conditiats of ApprovaUReasons for Disapproval <br /> IL <br /> Attach to complete plan for the syss nand nban totheCounty only on paper rot lea than 8 in x 11 lothm in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />