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cora.. eree.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 K h Li} <br /> Madison, I 53707-7162iseonsin <br /> Sanitary <br /> itPermit Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application Ststre Transaction N/uumber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,,xubmission of this forth to the appropriate governmental ( / L 4 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms fm state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary ddjeCe t .VLo; <br /> purposes in accordance with the Prieacy Law,s.15.04(1)(m),Slats. ^ rpt <br /> I. Application Information-please Print AB Information 11 0 at'T �a„f G4 <br /> Property Owner's Name n J a Parcel# p 7-O,tlf/•a{l97/dr 3e't� Oa' <br /> /e✓eJ 01ertfA 141Le4t�rr � ,,.)4 Poo- <br /> Property Owner's Mailing Address <br /> Property Location <br /> OJ-0t O 4 A/s c.f fn - /7R ' Govt.Lot <br /> City,State zip Code Phone Number <br /> ff• <br /> GNA,4 7`.S6 �ygyo N�Y Slt� Yn r Sectio4✓ W T 3 7 N; R /ycrtclE ane) <br /> IL Type of Building(check all that apply) �j Lot# o q5� <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑village of <br /> J9 Town of / Yrs WI Zk <br /> IID Type of Permit: (Check only one boa on line A. Complete line B if applicable) r)::?q_J. <br /> A. A New System <br /> El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Pemtil Renewal ❑Permit Revision ❑ Ch a of Plumber List Previous Permit Number and Date Issued <br /> ang ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onenVDevice: Check all that apply) <br /> ❑Non-Pressurized l.-Ground ❑Pressurized In-Ground ❑ At-Grade W Mound>24 in.(yof suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) }9 Pretreatment Device(explain) <br /> V.Dis ersaVfrea6umt Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 1 4 o ASS I )AS' G6. b <br /> Vl.Tank Info Capacity in Total #of Manufach, <br /> Gallons Gallons Units U $ <br /> New Tanks <br /> TS 4 <br /> Ezisdng Tanks v e o ° u b <br /> L� U iii � y ti C7 C. <br /> Septics Holding Tmdc so ` O (�/ta Ss✓' <br /> Dosing Chamber <br /> VII.Responsibility Statement-L 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 /> J2r c d lis` S66 c/is-� <br /> Plumber's Address(Sires City,State,Zip Code) <br /> X76 ,�r 3.f w-G6rfr� wr 5 4d�� <br /> VIIL Cour /De artment Use Ont <br /> Er'App...d ❑Disapproved Permit Fee rye Date Issued t. Issuing A ignature <br /> ❑Owner Given Reason for Denial 75-% 21 241 _ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atbeh b eompkte plan for the•Scree amt whmn b the CouNy oily an paper not res than 8 I z 11 inches in alae <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />