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commerce.wi.gov <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 13 1, r <br /> ' Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) W <br /> isconsin s3z�&z <br /> Department of Commerce <br /> State Transaction Number <br /> Sanitary Permit Application /G 3773 <br /> In accordance with s.Comm.8321(2),W is.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application fors for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal inforation you provide may be used for secondary <br /> purposes in accordance with the Privn Law,s.15. 1 m,Stats. '1 Q 1 <br /> I. A Head nInformation-Please Print All Information Parcel# / <br /> Property Owner's Name n J�.�^ <br /> C l�-1/- `�JG p .pO.ta'7yR-1-7-19-ill o L 000 <br /> LO ro- a Property Location <br /> Property Owner's Mailing Add s O 1 1 bofl <br /> ! F0 / �.e IS Govt.Lott �� <br /> City,State bb C.0 Zip Code Phone Number jA/ '/,,��'/., Section <br /> �) (circle on(��x/� <br /> k /QIh SS3 ZZo '�O�V T _N; R�].__E o7 <br /> II.Type of Building(check all that apply) Lot ik <br /> Subdivision Name <br /> 0(i or 2 Family Dwelling-Number of Bedrooms __— <br /> Block H <br /> ❑Public/Commercial-Describe Use El city of <br /> CSM Number D Village of <br /> D State Owned-Describe Use Town of D I'M I Q I S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. D New System %.Replacement System D T cument/111.1ding Tank Replacement Only D Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumb�[]PcrnfitT�ffftoNcovList Previous Permit Number and Date Issued <br /> Before Expiration <br /> IV. a of POWTS S stem/Com oneat/Device: Check all that a I <br /> ❑Non-Pressurized In-Ground ❑Pressurised In-Ground ❑At-Crede <br /> ❑Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑ Holding Tank 11 Other Dispersal Component(explain) <br /> ❑Pretreatment Device(explain) <br /> V.Dig ersal/I'reatment Area Information: pis ersal Area Pro sed s System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gP1 Dispersal Area Required(sf) P P° (t) ^-r <br /> (o 00 fl0 (p 00 l� <br /> Total 9 of Manufacturer „ <br /> VI.Tank Info CapacmTy.rn c u <br /> Gallons Gallons Units w e o ? v 2 <br /> New Tanks Existing Tanks E V y >' h <br /> Septicor Holding Taok 2so <br /> Dosing Chamber r` D <br /> VII.Responsibility Statement- I,the undersigned,a ante responsibility for installation of the POWTS ssM1 wn oMPIMPRNumber the tached Business Phone Number <br /> Plumber's Name(Print Plumbe's Signature <br /> els oeY r (,cam ZaSLZ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> '7 ( S GO ud e6s 4r u) <br /> VIII.Count /De artment Use Only <br /> Permit Fee Dare Issued Issuing en gnamre <br /> Approved DDisapproved $ ���G <br /> D Owner Given Reason for Denial 5 JD <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not tris thing rn x 11 inches m size <br /> SBD-6398(R.02109)Valid thru 02/11 <br />