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Commeree.wl.gov Safety and Buildings Division County <br /> • 201 W.Washington Ave.,P.O.Box 7162 ✓11 t? // <br /> seo n s i n Madison.WI 53707-7162 (3K <br /> Sani Ory ppermit//--N/m-nbe o filled n by Co.) <br /> Department of CommerceLt �s <br /> Sanitary permit Application StateTrmsaction Number <br /> In accordance with a.Comm.83.21(2),Wu.Adm.Code,submission of this form m the appropriate governmental /4177777 <br /> submitted to <br /> epriorDep to obtaining a sanitary Permit Note: Appli y ionpforms for spte-owned PI are (� <br /> Deparrmrut of Commerce. Personal information you rovide may be used for secondary Project Address(if different thin mailing address) �(J <br /> gain accordance Without <br /> Priv Law,s.15. I 'm),Slats. <br /> I. A ticatim Womnation-Please Print All lnformadm d S L l3 f R/m�f Crrf �r <br /> Property Owner's Name <br /> Parcel R <br /> Grp He FF <br /> Property Owner's MaiEng Address 03G 4y/3 oa S'ee <br /> 7 90 S 73N.ra( Property Location <br /> f7.a a <br /> city,ware zipe4ae cnvr.Lee <br /> /J rs O k/sur I/ Phone Number y Section <br /> h�a.. /G s's-y,e 7i 3—4"A If ver v <br /> IL Type of Building(dteck all that apply) Lot H G O 6 6 T t/p N, R 1 (circ E M152 <br /> ID' 1 or2Family Dwelling-Number ofBiximorrrs -3 a Subdivision Name 7 / <br /> ❑Publi1JComm Block b <br /> ercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSM Number 11Village of <br /> V. ao �jV ®Townof Un/Oh <br /> A. Type of Permit: (Check only one bo:m Ibis A. Complete tin \e n n applicable) <br /> A. New <br /> System ❑ <br /> Replacrment System ❑Tteatmmf/Holdiag Tank Replacement only ❑Other Modification to Existing Syetan(explain) <br /> H• ❑Permit ir <br /> 11 Permit Revision List Previous Permit Number and Date Issued <br /> Before Expvatitiout on ❑ChaoBe ofPlum6cr ❑permit Trarefcr to New <br /> Owner <br /> N.T e of POWYS S sleet/Com ment/Devlce: Check all that a <br /> ❑Noo-Pressurized lnGmund ❑pressurized In-Ground ❑Ar_cmde a Mound>24 in.of suitable Boil ❑Mound<24 in.of suitable soil <br /> ❑Bolding Tank ❑Other Dispersal Component(explain) <br /> ❑PretreatmeatDevice(explain) <br /> V• ers•l/Treamtmt Area hdottoatim• <br /> Design Flow(gp-, Design Soil Application Ra <br /> trtBPdsU Dispersal Area Required(af) Dispersal Area proposed(at) System Elevation <br /> VI.Tank Wo capacity in Total #of <br /> Galbns Mi°�achr <br /> New,Tad, Gallom Units <br /> Ne <br /> Existsg Tanks sCJIs <br /> _ po <br /> SePhc Or Ho 'gY 8 re w id <br /> Id'rg Tank /ODO �" - � � cc V iL <br /> Dosing Chamber /000 <br /> GOO BOO <br /> VIL ReaponsibBity Statemmt-I,the undersigned,assume responsibility for installation of the pOWTS shown on the an <br /> Plumber's Name(Print) plumber's Sigmmr, ached plans. <br /> MP/MPRS Nnmber/G/G /7/s Business Phone Number <br /> �C/nS <br /> Plumber's Address(Sheet,City,State,Zip Code) / s�ds—/ 7/S �66�Cf/•S"7 <br /> 7760 {/„ 3,4— WL6sf,gry wr SYY97 <br /> VIIL Cents /De arhnmt Use Only <br /> APPrm'ed ❑Disapproved Permit Fee Date Issued Issum <br /> S rgnatme <br /> ❑Own"Given Reason for Denial 30 �p I D 29 b7 <br /> IX.Cmditims otApprovaMeasoao for DLyapproval <br /> Afyeh b roaplete pyre for me ayaha and rehWt m the Courcy Only ao paper rot tea than S in a ll irchesin sial <br /> SBD-6398(R.01/07)Valid dant 01/09 <br />