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conimerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 U✓ry 9 "{7` <br /> y f i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Ccu marce 152) 0120 <br /> Sanitary Permit Application State Transaction Number <br /> N accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this Form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forma for 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 <br /> purposes in accordance w24 the Privacy Law,a.15. 1 m),Slats. �• <br /> I. A timtion Wormation-Please Print All Information 3 t77 1Y O i,7✓a GAS�t a w / <br /> Property Owner's Name ' <br /> MIN <br /> 01'e-le 5t4 2� 03a - sa) �- a3600 <br /> Property Owner's Mailing Address Property Location <br /> /36S" Mc l<at.s;ck Ad' Ln /V• Z <br /> Govt.Lot - <br /> City,State Zip Code Phone Number -Vg '/a, Section /9 <br /> 5f:/�wafY✓ W7 SSo Bot bs-/- 4ae- 46 s9 T �// N; R 15-- <br /> (circle <br /> IL Type of Building(check a6 that apply) )) Lot# <br /> Q f or 2 Family Dwelling-Number of Bedrooms R Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> gTownof -swn J,s <br /> III.Type of Permit: (Check only one box on tine A. Complete tine B if applicable) <br /> A. ❑New System Replacement System ❑Treatnumt/Holding Tank <br /> Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S tem/Com mt/Device: Check a6 that apply) <br /> 9 Non-Preasuraed In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in of suitable soil ❑Monad<24 in of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑pretreatment Device(explain) <br /> V.Dispersal/Treatment Arm Wormation: <br /> Design Flow(gpd) Design Soil ApplicationRate(gpdat) Dispersal Area Required(at) Dispersal Arra proposed(et) System Elevation <br /> Io0 7 qk-7 �r3/ <br /> VI.Tank Info Capacity in Total #of Manufacturer pp <br /> Gallon Gallons Units y o$ o <br /> New Tanks Existing Tanks Y 66 r+ �b ze q <br /> f>; N rn C7 0. <br /> Septic or HOkling Tank <br /> X <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown am the attached plans. <br /> Plumber's Name(Print) Plumber's Signature WNUIRS Number Business Phone Number <br /> ✓2rc/c #0 ✓e ins ✓fir cru ,�-- /Z{ '711s- 6766- v/5-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7-76D Al, w-e6-Tt<✓ Gv� SY ��3, <br /> VII Cour /De artment Use only <br /> Approved ❑Disapproved Permit Fee Date Issued Isauin Signature <br /> S <br /> 3o 30 _ o� <br /> Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reastans for Disapproval <br /> Attach to msphr plum fur&a system and submit loth County only on paper not les them 8 to a 11 inches in alae <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />