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eommerce.wi.gov Safety and Buildings Division County <br /> a201 W.Washington Ave.,P.O.Box 7162 t <br /> V 2 r <br /> i s e o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce Z 1 C <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.93.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �y Rude.) <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,Slats. / Q <br /> I. Application Information-PleasePrintAllInformation / {e Rodd 70 <br /> Property Owner's N/ame �JPacel# >orm 2Q0 0/200 <br /> C Xo ( i9 u / Soni co:#- o7-0C<--2-W-17--20-1 of-oro o/lax, <br /> Property Owner's Mailing Address Property Location <br /> `7 � 1 s �o � fi lz/ 7� Peaty/ m <br /> City,State Let <br /> Zip Code Phone Numher <br /> �, _ / ryry VJE'/.,_1✓ Yti Section .G <br /> W ^Y8' L 7/) G k/'-Z l GJ T 7 N; R._(�4/E on W <br /> II.Type of Building(check all that apply) Lot N <br /> l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 11 Village of <br /> Vol 3 P /23 ff Tow'nofJJA,vt e 15 <br /> III.Type of Permit: (Check only one boz on line A. Complete line B if applicable) <br /> `t'' ❑New System Replacement System reetmentR (tan/ Tna!(ReplaccormlOnly ❑Other Modification to Existing System(explain) <br /> ' <br /> B- ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Lssued <br /> Before Expiration Owner // 6 ? <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑Non-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 rsaVi'reatmeor Ares Information: f5 r n/ <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispe Area Required(sf) Dispersal Area Proposed(if System Elevation <br /> VI.Tank Info Capacity in Total a of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks La Talcs a <br /> God o GU� ! $� (2-, riU ti wC7 w <br /> Septic or Holding Talc t� 1COD <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MRRSNumber Business Phone Number <br /> d/ 2 -71 9 ,5—/ 7/s 3 Y It —5-2 (o� <br /> Plumber's Address(Street,City,Staze,Zip Code) <br /> VII oun /De artment Use Onl <br /> ER"Approved ❑ Disapproved Permit Fee Date Issued Issuing gname <br /> r <br /> ❑Owner Given Reason for Denial &,Z57% 18 Jtw G9 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Sort His rutltGobe 3838 - Nu4ZaIDl /O" 6AIV <br /> mfrs&»(- WiEk sate ftaA✓t (115) 3y RoAeUk NpgjV$ <br /> i)oloal `f/3/ 87 4e <br /> v <br /> Attach to complete plans for the system and submit to the County only on paper not less than b to z 11 inches io size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />