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commerce.wi.gov Safety and Buildings Division Con L <br /> 201 W.Washington Ave.,P.O.Box 7162 (� ) a4 e 1 T <br /> is e o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce SS 1.2.?e4 <br /> aon <br /> u <br /> Sanitary Permit Application State T ctiNbr <br /> In accordance with s.Comm.83:21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (ce40 13} <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) `� 1 <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. 1 m Stats. 3;)V7 OId 3-5- S"-f <br /> I. Application information-Please Print All information r f�Jl <br /> Property Owner's Name (60-=H-356 <br /> Parcel# pp(y• �.pas.Gpp <br /> L 2 e� M i 7�r-tel( - 1 VvslL D� Od�'2-3b t7 zl S oa Go3_olSoro <br /> Property Owner's Mailing Address 1 7 Property Location <br /> )'Yl� 21L'C s4, Apr w> Govt.Lot _ qq <br /> City,State Zip Code Phone Number``// y,, y,, Section aaD- <br /> &r", ciwxA Q .AA S.S 1i 3 763 )V -1955 T3 N; R ' circle one <br /> II:Type of Building(check all that apply) Lot# <br /> �(l or2 Family Dwelling-Number ofBedrooms_. 3 5— Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> [I State Owned-Describe Use CSM Number 11 Village of <br /> 'f� <br /> V1 .p q I Tnwn of YQ h�P(s <br /> III.Type of Permit: (Check only one box online A. Complete line B if of pplicable) <br /> A' ❑New System 18 Replacement System ❑Treatmenr/Nolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑PermitRevision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner - <br /> IV.Type of POWTS S stem/Com onentWevice: Check all that apply) <br /> - <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable suit <br /> 19Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed is System Elevation <br /> 14so <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units -O <br /> U <br /> New Tanks Existing Tanks <br /> P.U ti y H ii C7 i>r <br /> rtene Holding Ta 0 I I lOs�r X <br /> Dosing Cham er <br /> Vll.Responsibility Statement- I,the undersigned assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's <br /> Name(Pr t) Plu er's Signature MP/MPRS Number Business Phone Number <br /> Ale is <br /> Plumber's Address(Street'City,State,Zip Code) <br /> 78 s- 60t 0-17 ,?d ( -e` ( fJr sysf <br /> VI I.Count /De artment Use Only <br /> Approved 1 ❑Disapproved Permit Fee Datge Issued 22.. Issuing ignature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> NW- 664;1j 771mt- s,6e r9 Dot, tr)iii(c* ( to k- (vtFlt k 16 he, AC F7od Plata Dp aHent �4&. 8FE 978.0 Af%L <br /> ( _ <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 12 z l t inches in size <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />