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corDDlercemi.goV Safety and Buildings Division Cooney,,, <br /> 201 W.Washington Ave.,P.O.Box 7162 Turn tl`� <br /> �i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Dwarttnem a commerce 4 O V(03 D <br /> Sanitary Permit Application State Transaction Number I� 1� ') <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental �- 0i <br /> unit is required prior to obtaining a sanitary permit Note: Application fonts for statoowned POWTS me Project Address(if differvia than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary l\I`ll <br /> p!nwnes in accordance with the Privacy Law,a.15. 1 m),Stan. 7� <br /> I. Application Information-Please Print All Information 7aHy CO �O u <br /> Property Owner's Name Parcel p <br /> /ann o/+nfoat <br /> oaao z13�ri o3/oD <br /> Property Owner's Mailing Address Property Location <br /> Aky Lh Govt Lot d <br /> City,State Zip Code Phone Number y4 Sec[ 11 Section <br /> Gs/den t*ae /Yl N S3-4'J 7 (circle one) <br /> IL Type of Building(check an that apply) rn� Lot H T Zf0 N, R 16 E or® <br /> 1 m 2 Family Dwelling-Number of Bedrooms O. Subdivision Name <br /> Block 9 <br /> ❑Public/Commescial-Describe Use ❑ City of <br /> State Owned-Describe Use CSM Number r❑Village of <br /> ,a Townof O/fk/�has� <br /> IIL Type of Permit: (Check only one bo s m tine A. Complete tine B if applicable) <br /> A. New System <br /> ❑Replacement yatem Rep System ❑Treafmrnf/Holding Tank Replacement Only ❑Other Modificative to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ ChmgeofPlumber ❑Permit Tranfer to New List Previous Permit Number and Date Issued <br /> Before Eximation Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> IgNon-Pressurized InGround ❑Aessurized In-Ground ❑ At-Grade ❑Mound,24 in.of audablc soil ❑Mound<24 in-of suitable sod <br /> ❑Bolding Tank ❑Other Dispersal Compoamt(explam) ❑Prctreatmeat Device(explain) <br /> V.Dispersal/Treatment Area lnformatims: <br /> Deal Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> BO . 5- 600 <br /> /o tso 9y.o 1 93, D <br /> VL Tank I db Capacity in Total q of Mamrfacmrer <br /> Gallons Gallon Unit c V <br /> New Tanks Existing Tanks `t3 U u 8 c eSi <br /> cCA "v, <br /> Septic or Holding Tank ger p I?�O SKr✓ .t(! <br /> Dosing Chamber <br /> VII.Respon96itity Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Amt) Plumber's Signlure MP/Iv1PRS Number Business Phone Number <br /> Risk #" /Crgr /?iu�-.� s8sl 71s-866-9/ST <br /> Plumber's Address(Street,City,State,Zip Code) <br /> e(7760 WF 35- webs-At-, ter Srfg93 <br /> VIIL Cam /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date[sued Issuing tore <br /> j2-7❑Oaner Givrn Reason for Denial <br /> IX.Conditions of ApprovaVRearoaas for Disapproval <br /> Attach to complete plow for the system mod submit to the Comy only m paper not les than a in a it Inches it size <br /> SBD-6398(R,01/07)Valid thin 01/09 <br />