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Commeree.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> i sco n s i n Madison,WI 53707-7162 Sanitary Permit Numberramme (to be filled in by Co,) <br /> Dapi rlmnt of Corce sz i �6 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental <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 /> submitted 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. �( <br /> 1. Application Information-Please Print All Information d3.2-0 Co. J4w� YC <br /> Property Owner's Name Parcel pUc/ p <br /> �9 f2 rZ �'/Itf�r� /�ig!/(i o7-03 Z-�/ / 1 ZS Z o� oor� <br /> Property Owner's ailing Address r� Property Location <br /> J 03 P 8 C dr7L )Q U f / Govt.Lot <br /> City,State Zip Code Phone Number ��(,(� �1 y, Section a 10 <br /> �AN�UV CJ f 5- 9--i?0 759 ( 'rdeonyyYY�� J <br /> Il.Type of Building(check all that apply) Lot q <br /> � <br /> TN; REoIVp(1- <br /> KI or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name U} <br /> Block q -- ...�. <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number .1.53,107 ❑ Village of '�1 <br /> V()(, / 1 7 X'Town of A)Ee$ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> A' yy New System y 11 Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ 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 a I <br /> XNon-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.Dis ersalfrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> -7 �71Z Zs'a - s9 <br /> VL Tank Info Capacity in Total k of Manufacturer <br /> Gallons Gallons Units , `o <br /> New Tanks Existing Tanks U <br /> Septic or Holding Tank <br /> 5;Q POM/-1[r7--) S 756 <br /> Dosing Chamber !r-M,Gv t.I <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PIuMbes-s,§nature ( MP/MPRS Number Business Phone Number <br /> ?eft— 3 SCl't <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 11c7�3 5. s Ab 35 641-&0am <br /> VII oun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing A t S' nature <br /> ❑Owner Given Reason for Denial � ii/ A0, (J$ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plane for Me system and submit to the County only on paper not Ins than 8 112 x 11 Inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />