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commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Q/.2/-h c <br /> i s e o n s i n Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of commerce ` i/32. <br /> Sanitary Permit Application State TrransactionGNum(beer <br /> In accordance with s.Comm.83:21(2),Wis.Adm.Code,submission of this form to the appropriate governments] <br /> unit is required prior to obtaining a sanitary permitNote: Application fortes for stateowned POWTS are project Address(ifdifferentthanmailin$addresj� / <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Sl(Jc,7, <br /> _Rurposes in accordance with the Privacy Law,s. 15.04(1 m),Stats. <br /> f. Application Information-Please Print All Information 1 <br /> Property Owner's Name Par"I4 <br /> —42 <br /> V <br /> aItel 'fJ ah / Ker �/ua�7` � , 07-oiv-a-38-/r- 0- <br /> Property Owner's Muting <br /> /Address Property Location <br /> v8 Govt.Lot <br /> City,Stale Zip Code one Number 0 <br /> ��y S E Y.,__ LA, Section <br /> '• �f. -'�.3`/� a6a-7a 5�-s.r3 ((circle one)_ <br /> II.Type of Buildin check all that apply) Lotg T 38 N; R /S— Eo <br /> YP ( PP Y) �1 <br /> �or 2 Family Dwelling-Number of Bedrooms og Subdivision Name <br /> Blockfl <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSMNumber El Village of _ <br /> ]'Town of CC �O Ile t: <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ys �Replacemrnt System ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Numberand Date Issued <br /> Before Expiration Owner <br /> IV. a of POWTS System/Component/Device: Check all that apply) <br /> l�3 Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 11 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaV[reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area �i <br /> ac) �e 6 S00 �U S Pro�osed(sf) Sys�3. V <br /> VI.Tank Info Capacity in Total 0 of Manufacturer <br /> CCJJ <br /> Gallons Gallons Units d c <br /> New Tanks Existing Tanks U y <br /> R 0 3g u aA is <br /> m <br /> Septic or Holding Tank 7sO 7S U 1 l <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> i✓iii« J , Jz I c am I, qs 7/j <br /> Plumber's Address(Street,City,State,Zip Code) � <br /> SYS' �.14l< ReAo/ /?c/ 41e ✓ <br /> VIII.Cozen /De artment Use Only Approved 11 Disapproved Permit Fee Daze Issued Issuing gesture <br /> S . <br /> ❑Owner Given Reason for Denial 3. J,P M Aot(, 2010 <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In s 11 inches in sift <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />