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commerCe.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 StA E tl <br /> iseonsin Madison,WI 53707-7162 Sanitary Perm n t Number(to be filled in by Co.) <br /> r�of Commence, 4 56� Z <br /> Sanitary Permit Application State Transact on Number <br /> In accordance with a.Comm.53.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �- <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms fm state-owned POWTS are Project Addy a(if different than mailing address) <br /> submitted to the Department of Comme e, Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1 m),Stan. 3 0 6 7 T O v L& <br /> 1. Applicatim Infornration-Plesae Print All Information <br /> Property Owner's Name i' Parcel R <br /> Js o^414an �rett5 rI �0�3�5 0.3x1 - Sd/�j 01800 <br /> Prop"Owner's Mailing Address property Loca'on <br /> -7 1.13 Car l .SY Govt Lot <br /> City,Stam Zip Code Phone Number <br /> Yy Suction II <br /> jr... roa.l /N/t/ --f- Gar /045- /-7 N/ (circle one) <br /> rit <br /> IL Type of Building(cheall that apply) Lot 8 T R /,r E o69 <br /> ®I or 2 Family Dwelling-Number of Bedrooms Subdivision N we <br /> Block 5 <br /> ❑Public/Comme cial-Describe Use ❑City of- <br /> 0 State <br /> f❑Stam Owned-Describe Use CSM -Y Number 11 Village of <br /> V,-3 a I('t';) Town of Ss.-rJ1 <br /> IIL Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A. ❑New System ®'Rephcoment <br /> System ❑TrealmenNHolding Talc Replacemrat Only ❑Other Much kation to Fautmg System(explain) <br /> B. ❑PermitRenewsl ❑Permit Revision ❑ ofphnnber List Pmieus ' Number and Date Issued <br /> Change ❑PermLL Tramfer b New <br /> Before Expirstiw Owner <br /> IV.Type of POWTS S Com ent/Device: Check all that apply) <br /> ®Non-Pressured In-Ground ❑pressurized lo-Gmouod ❑AI-Gnde ❑Mmmd a A in.of au0ableamt ❑Mound<2 1 is of suitable soil <br /> ❑Holding Talc ❑Other Dispi Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersolfrreatement Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Disposed Area Required(a]) Dispersal Area <br /> Proposed(sfJ System Elevation <br /> )S a 7 ,t/.fG- ak/ 90. .1 <br /> VI.Tank hdo Capacity in Total p of Manufacturer <br /> Gallon Gallons Units jti o 0 <br /> New Tanks Existing Tanks <br /> N . <br /> Septic or Holding Tank .SBO X00 SrL"w w. X <br /> Daarg Chamber <br /> VIL Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the matim ched pian& <br /> Plumber's Name(Print) Plumber's Signature MP/MORS Number Bottom Phone Number <br /> Rle-IL %//o"i / eQ el,srrrsr lis S6G -�/ir� <br /> Plumber's Addeees(Street,City,Stam,Zip Code) <br /> X760 'Y.- Y 3S— r ve6 r t4 r tiz sYQs <br /> VII mm /De artment Use Only <br /> Approved ❑Daapproved Permit/F'wll Dam,Issued Issuing 086di <br /> lantern <br /> ❑Owner Given Reason for Denial <br /> DL Conditions of Approval/Ressosas for Disapproval <br /> Attaehta complete ptam fartiw sysh.ed aubmll mthe Camaly aaiyen paper sults tYmarrs xil lneM ustae <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />