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commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 94 <br /> i seo n s i n Madison,Wl 53707 7162 Sanitary Pr���nnnit Numb (o be filled m by <br /> Department of Commerce `' / O <br /> Sanitary Permit Application SateTa action Numbs <br /> In accordance with a.Comm.83.21(2),Vora.Adm.Cade,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Applimtion forms for stateowned POWTS are <br /> submitted to the Department of Commerce. Personal information you provide may be wed For secondary Project Address(if different than mailing address) <br /> ees in aceordaene with the Priya Law,a.15. 1 m),Stab. 7304 73 <br /> L A Beatim Wermation-please print AB Informatim Ell of .Jd�i ry J a n R41 <br /> Property Owner's Name <br /> Parcel# <br /> Do ,t n 03,1 Sdd(a — o s 70 D <br /> Property Owner's Mailing Addtese <br /> .{� Property Location <br /> s9� 4/etr rL�saOe- Lwne cove Lot <br /> Cuihf.State Zrp Code Phone Number <br /> /i ri �G wieGP /t1N .�S// '�5 Yy Section <br /> (ehcb one) <br /> IL Type of Building(check an that apply) Lot# T W N; R /r E c(S5 <br /> ❑1 m 2 Family Dwelling_Number.ofBedrooms Subdivision Name <br /> Block# <br /> ❑Pubhr(Comm.W_Describe Use <br /> ❑City of <br /> 11 State Onrned-Describe Use CSMNumbm Village of <br /> Er Town of fie,r1t <br /> III Type of permit: (Cheek only one box m rte A. ComA. plete line B if applicable) <br /> ❑New System Ys <br /> ya Replacement System ❑Treatmeot/hoWiog TankEepiac®ent Only ❑OWerModificatiom to Existing System(explain) <br /> B. ❑permit Renewal ❑Permit Revision ❑ ofP(tanbes ListPrcviom Permit Number and Date Lsued <br /> Below Expiation Chamg6 ❑Permit Tramfesto New <br /> Owner <br /> IV.T of PORTS S ahto/Com et/DeA"- C7teek add that a <br /> ®Non-prusurued In it <br /> ❑pre"or-d in-Ground ❑At-Grade ❑Mwmd>2A is of sn4able and ❑Mouad<24 im of nibblesoil <br /> ❑holding Tank ❑0thm Dispersal Component(explain) ❑PreircatmentDovice(explain) <br /> V• ■Vrreatment Am Information, <br /> Design Flow(gpd) Design and ApphcaUm Ram(gpdaf) Dispersal Area Required(of) Dispersal A�r�ea sed(at) System Elevation7 G ti 3r (Y 9160 <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> GaSom <br /> Ga <br /> New TwJa §;-. Twtla gom Unit b <br /> y 3 is <br /> Septic QFloldHgTwilc 7S0 <br /> Doffing amber 7So <br /> 61)D Ss0 <br /> VIL RwponsibBity Smtemet-I,the mndnrsigned,assume rmponai6aity for installation of the POWTS shown on the attached plan, <br /> Plumber's Name(Print) Plum'ber's Sigoatme W70h S Number Bmioess phorm Number <br /> MMI/?ecna/cdm,. s/�� /�••r s /C '�d <br /> ( trent, ity,state,Zip Code) <br /> 77 ae f/w 3s- /tet/26s><r G✓ r S4 8 93 <br /> VLIL Cams /De armlet Use Otd <br /> Approved ❑Disapproved Permit CFe/el Date,hand Imumg �gmture <br /> ❑Owner Given Reason fm Denial <br /> $2JV � ?///'MUL W <br /> IX.Cmditims M ApprovaUReasms for Diaapploval <br /> Atbehb mmpM plum for ths systeR ad"hink to the CWaty sob,an paper sot Ws mm a M x 11 inch"Insist <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />