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ON COMPUTER/SCANNED <br /> COftNllefCe.Wl.gOy Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 84✓me <br /> i sC of n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> oapamnem Commerce 149e 4w <br /> Sanitary Permit Application Blasts Trsna"4on Number <br /> Is accordance with s.Comm.83.21(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 for state-owned POWTS are Project Address(if different than mailing address) Le <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1 m),Stab. <br /> L Application Information-please Print All Information <br /> Property Owner's Name Parcel It <br /> Mtr•,•/y„ Sett=b.. ti �c�, OS dda v3a8oa/ao <br /> Property Owner's Mailing Address Property Location <br /> 7//O G 6/Yt /2eP• Govt.Lot <br /> City,State Zip Cade Phone Number Sk! y,, SE Y, Section 01 J, <br /> Lll edt fe✓ W.� SyP9.7 7/S= X66- 760 (circle one) <br /> IL Type of Building(check all that apply) /J Lot# T �/0 N; R /6 E o® <br /> 1 or 2 Family Dwelling-Number of Bedrooms -/ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ViWge of <br /> ry <br /> Cl Town of L7,4_14A�41 <br /> IIL Type of Permit: (Cheek only one box en fine A. Complete fine B if applicable) <br /> ❑New System pp Replacement System ❑Treahnmt/Holdin TankRepla.t <br /> Only ❑Other Modification to Existing System(explain) <br /> B. ❑PamitRenewal ❑permit Revision ❑ChangeofPlumber ❑Permit Transfer to New List Previous Permit Number and Date tweed <br /> Befom Expiration Owner <br /> IV.T of POWTS stem/Com orunaVDevice: Check all that apply) <br /> Z Non-Prmsurized In-Ground ❑Pressurized In-Ground ❑ At-Cmde ❑Mound>24 in.of suitable soil ❑ Mound<yt in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Prehcatmmt Device(explain) <br /> V. a1/freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Areauired <br /> Req (sf) Dispersal Area Proposed(at) System Elevation <br /> e a 1 . .5— / ors I /,(ars <br /> VL Tank Wo Capacity in Total #of Mamnfacmrer <br /> Gallons Gallons Unit < g y <br /> New Tendo ENsdrg Tanks 2u y $ <br /> A. A W 3 Mw <br /> Septic or Holding Tank 7j-0 a' POU /S­�' 1 1 .1 <br /> Do.%Chvnber <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown an the attached plans. <br /> Plumber's Name(Print) Plumber's Sig umre MP/MFRS Number Business Phorx Number <br /> Rt l_.rc Ha le'!!-f /2"t !«+e� l��s� 71 s= 96� - v.s-7 <br /> Plumber's Address( [reef,city,site,Zip Cade) <br /> 776a //r . .3S We6sfn- <br /> ioOnly <br /> ,VDL Cn /De artment Use Ont <br /> CI Approved 1 ❑Disapproved Permit Fee Date Issued Issuing Signature <br /> ❑ Owner Given Reason far Denial 9, IloM4Y 07 <br /> DL Conditions of ApprovaVReasotn for Disapproval <br /> Attach to eonsptete plans for the sys4n and submit to the Couely only an paper not hes then d in x li Inches bate <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />