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commerce.wl.gov Safety and Buildings Division Comry� <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,WI 53707-7162 Sani <br /> iseonsasn �Pumi[Numbe (obetlledinbyCol <br /> DcpartmeM of comm.ro. <br /> Sanitary Permit Application State Tran nnNumbe <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submusiort �u form to the appropriate governmental � 7 f <br /> unit is required prior to obtaining a sanitary penrdL, Note:Applioation forma for stato-owned POWTS are project AQdress(ifditferent than mailing address) <br /> su'mitted to the Department of Commerce. Pen01W information you provide may be used for lewndary <br /> u ses in accordance with the Priva Law a.15.04 1 M'Stat. �J <br /> I. A lication Informstion-Please Print All Information YYIDOn <br /> Propem Owner's Name <br /> Parcel# <br /> to ! �.. nn; Sf^R `��—rl 'l�3 oxos8-z-Yo•f4-zrS <br /> Property Own ailing Address Property Location -0 0000 <br /> 14-72) T A 0 1/F.. Govt'Y,ot 2-- <br /> Gtc,Stxte Zip Code - Phone Number <br /> T1C,C %, '/., Section 2s <br /> ti w Pyla - 55108 i - 7 - l9 �ctmle m <br /> II.Type of Building(check all that apply) Lot# T46N; R �`'! E t W <br /> �J 1 or 2 Family Dwelling-Number of Bedrooms 3 ' Subdivision Name <br /> PubliUCornmercial-Describe Use Block# <br /> � ❑City of <br /> State Owned-Describe Use CSM Number 0y Village,of t <br /> V, p 7S VJ Town of 'x60 <br /> III.Type of Permit: (Check only one box on line A. Complete Ene B itapplleable) — _ <br /> A <br /> 11 New System- Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> E. ❑ Permit Renewal ❑ Permit Revision ❑ Change Plumber List Previous Permit Numberand Dateissued <br /> B ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com onent/Device: Check all that apply) <br /> J Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable so0 ❑Mound<24 in of suitable soil <br /> XIdolding Tank 0 Other Dispersal Component(explain) <br /> ❑Preoeatmen[Device(explain) <br /> \,Dis ersa VTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required Dispersal Area Pro sed <br /> 450 lAe� _ I po ('Q System Elevation <br /> VI.Tank Info Ga- <br /> Capacity in Total #o Manufacnuef <br /> Gallons Gallons Unit N e v <br /> h'cw Talcs Existing TWts '� `u' 0 y <br /> yy u <br /> S U in in w V LL <br /> �+yxeeNi oldmg Tank .7000 <br /> Dosing Chunber oC V <br /> VII.Responsibility Statement-I,the undersigne ,assume respomibtl' for installation ofthe POWTS ahaws. <br /> n on the attached plan <br /> & EXCAVATION Plu bar lure MP/MW Number Business Phone Number <br /> aay5 <br /> Plum r K4 �Tr o c) <br /> r 4 <br /> VIII.Count a artment se nl <br /> Lf Approved ❑ Disapproved Permit Fee Dateelasted "- Issuin Age <br /> r_1Owner Given Reason for Denial $3,75� �,JNtZ UY�1I <br /> 11. Conditions of Approval/Reasons for Disapproval <br /> }� Stxftlit &s Fug on-5/k ,kir/ 46sor/ftnc cell IS Aumlalle D D <br /> 1 :Nf 2 F 2011 <br /> Attach to complete plain for the syalem and submit to the County only on papa,not la than 9 M.11 inch.In sixe <br /> v . BURNE <br /> SBD-6398(R. 01/07)Valid thin ZONING OI/09 � ' <br /> r ;. <br />