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Commeree.wl.gov Safety and Buildings Division Cowry <br /> 201 W.Washington Ave.,P.O.Box 7162 u ti e <br /> "Wisconsin Madison,WI 53707-7162 Sanitary„P/e�rm.,it Number(to be filled in by Co.) <br /> aparlment of Conumme <br /> Sanitary Permit Application State Transaction <br /> nnNumber \\ <br /> N accordance Adm Code,s.Comm.83.21(2),Wis.AdCode,submission of this form to the appropriate governmental tiS� i(ieLm e.J <br /> unit is required prim to obtaining a sanitary permit. Note: Application forms for state-owned POW I S are Project Address(if different than mailing address) <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 to,Slats. <br /> L Application Information—Please Print All Information Z77Z0 /Vvrwa� �4tHt K42�t <br /> Property Owner's Name {,� Parcel# d -7- OY - ”- -�o- <br /> ` I e> O'S ©G u" Ooe5 <br /> Property Cumer's Mailing Address Property Location C <br /> , -7,2 o - ®rLlf Govt.Lot 3 <br /> City,State / Zip lC�odpe c/ Phone Number /y Section -7 O <br /> td:E: �! 0 ! O y(7 S73 circle one <br /> TN; R Eo� <br /> IL Type of Building eck all that apply) rr77 Lot# <br /> -}or 2 Family Dwelling-Number of Bedrooms I;z Subdivision Name <br /> Block# <br /> ❑PubEdCommercial-Describe Use — <br /> ❑ City of <br /> `J <br /> ❑SCSM Number El Village of <br /> State Owned Use Mown of <br /> IIL Type of Permit: (Check only one box on line A. Complete tine B if applicable) en <br /> `- ❑New System �LReplacemeut System ❑ Treatmetn Holding Tank Replacement Only ❑ Oster Modification to Existing System(explain) <br /> B- ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Pemtil Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type ofPOWTS System/Component/Device: Check all that apply) <br /> !'--N--Presanrized In-Ground ❑ Pressurized In-Ground ❑ AbGmde ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Sod Application Rate(gpdst) Dispersal Area Required(d) Dispersal Area Proposed(st) System Elevation <br /> ,3oo 1 / 7 ,;z9 5'Sd <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u <br /> New Took. Dusting Tanks o Pdd <br /> a U <br /> Sapdc or Holding Tank 75-777 �- <br /> Dozing Chamber <br /> VII.Responsibility Statement-L the undersigned,snaame reapoosibMty for hntaludon of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> le 141177 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL County/Department Use Only <br /> Approved 1 ❑ DisapprovedPermit Fee Date leaned taming Ag tgnalure <br /> S <br /> ❑Owner Given Reason for Denial 3/2,52 /3 APRT L ,& <br /> DL Conditions of Approval/Ressons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In:11 Inches in size <br />