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commerce.wi.gov Safety and Buildings DivisionConn /+ <br /> Lt <br /> 201 W.Washington Ave.,P.O.Box 7162 u r h 'T <br /> i s eo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce J5-,3 1 6, 6 <br /> Sanitary Permit Application State Transaction ZLsacttiionNumber <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental Z Zft-w &U,e") \ 1 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stateowned POWTS are Project Address(if different than mailing address) v <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.15.04 1 m,Stats. <br /> I. Application Information—Please Print All Iaformatio L4_1 <br /> Property Owner's Name/' Parcel# <br /> C-ere 07 8 el- -z8�/ 6 SCIS oea <br /> Property Own 's Mailing Address / Property Location <br /> a—_763 CQ i, ¢AV All Govt.Lot' g <br /> City,State II — Zip Code Phone Number y, yr, Section 36 <br /> f4t,7S r rcle one <br /> Y Y t `f0 yD lot# F76 / '�7e�- I T��N; R Eor� <br /> II.Type of Building check all that apply) ^� Lot# <br /> 91 or 2 Family Dwelling-Number of Bedrooms 1D__ 3 Subdivision Name <br /> Block# 0 <br /> ❑Public/Commercial—Describe Use 0 City of <br /> El State Owned—Describe Use CSM Number 11 Village of _ <br /> 4tq/ytg UC LL Town of/y / IVQf <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicab ) <br /> A. yyfNew System <br /> ❑Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner _ <br /> FV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> tO Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> El Holding Tank 0 Other Dispersal Component(explain) 0 Pretreahnent Device(explain) <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3oa . y so '7 3Z �o - �1z.•o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> 0 <br /> 0. V in � h wr7 0.. <br /> Septic rH.1ding Taok "7 SD <br /> / <br /> Dosing Chamber u,// <br /> VII.Responsibility Statement- I,the undersigned,wfurne responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pri 0 Plumb e s Signature MP/MPRS Number Business Phone Number <br /> Ale <br /> lS v r 2 --"Z.L _71Y- cY66�-kbe <br /> Plumber's Address(Street,City,State,Zip Code) <br /> V ( &s4er tot <br /> VIII.Count /De artment Use Onl <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing ;gnatme <br /> 0 Owner Given Reason for Denial 1 325 'vl.p .cC> Jut 09 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 504 AWWt6o t cal( 51"-( G 04 6W7 9dy 0Lt- bo &SODre a S 4( nwk je. 4f <br /> Attach to complete plans for the system and submit to the County Daly on paper not less than 8 in x 1I inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />