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.W90ySafety and Buildings Division County <br /> 201 W.WasHngtonAve.,P.O.Box7162 Rwrrl 7f"t(scor'"'Orc <br /> em rcsin Madison,WI 53707-7162 San'itlarIy Perm Number(to be filled in by Co.) <br /> mparbmm�t of Commerce "'1'9 f jg, f36 <br /> Sanitary Permit Application Sante Transae °n Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental / 4) 3 p& 1 W <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stateowned POWTS are Project Ad dr (if different than mailing address) <br /> submitted to the Department of Commerce. personal information you provide may be used for secondary90 <br /> '/Q�S <br /> an in accordance with the PrivacyLaw,s.15. 1 m,Stals. O <br /> L A nation Information Please Print All Information IV E IS�� gr• <br /> SS <br /> Property Owner's Name Parcel# <br /> B&4t I jotinson 03d. 3-31} Oil 000 <br /> Property Owner's Mailing Address Property Location <br /> 3079 Ywv 3s— G <br /> City,State Zip Code Phone Number '/y Yc, Section y1�d <br /> 30 'pit- 6.rb - YS-,f 7 T yl R /bE oce`� <br /> D.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision N me <br /> Block# <br /> ❑PubGdConsummial-Describe Use ❑Cityof <br /> ❑Slate Owned-Describe Use CSMNumber ❑Village of <br /> ®Town of <br /> III.Type of Permit: (Check only one box on lite A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System ❑ TrcalmmVHoWing Tank Replacement Only ❑Other Mo 'nation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑PermitTransferto New List Previous it Number and Date Issued <br /> Beim Expiration Owner <br /> IV.Type of POWTS 3 tem/Com ent/Device: Check all that apply) <br /> ❑Non-Pressurized Ia-hound ❑Pressurized hr-Gerund ❑ M-Grade ❑Mmmd>_24 in.of suitable soil R Mound< im of suitable soil <br /> ❑Holding Talc ❑Other Dispersal Component(explain) ❑Preneabrmt Device(cxpbin) <br /> V.DispersaYrftatment Ara Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(or) Dispersal Area Proposed(sf) System Elevation <br /> 6 1 1 . 9 1 600 1 67,1 gf s3 <br /> VL Tank Info Gpscity in Total #of Marmfacturer yqqq <br /> Go om Gallon Units o II o 0 <br /> New Tads Eximgg Tanks - U ? <br /> Septic or Holding Tank <br /> Doing Chamber 7X7 7.f0 <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the an hed plans. <br /> Plumber's Norm:(Prmt) Plumber's Signature WINIPRS Numb Business Phone Number <br /> e—k As /e.'.r-1 1 /a., . !`� o)dS8S/ 21-1- P6 6 - vis 7 <br /> Plumber's Address(Shwre City,State,Zip Code) <br /> ,177 0 Af a 3S e4l e6-rY'w- w1 SY89� <br /> VIIL Gist /De srtmdmt use Ordy op <br /> Approved ❑Disapproved I Permit Fm Date Issued Imumg Si <br /> ❑Owner Given Reason for Denial 1 ',300* <br /> 300* 07 <br /> IX.Conditions of Approval/Reamms for Disapproval <br /> Attach m mesplem plan for the system and submit to the Canty only on paper PA les than 8 in x 11 inert ndw <br /> SBD-6398(R.01/07)Valid thru 0l/09 <br />