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commeree.wl.gov Safety and Buildings Division <br /> 201 W,Washington Ave,P.O.Box 7162 <br /> sconsin MadisonCounty <br /> i ,WI 53707-7162 uYNf <br /> Department of Commerce Sanitary Permit Number(to be tilled in by Co.) <br /> Sanitary Permit Application 3VO� <br /> State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form ro the appropriate govanmmot // <br /> tout is required prior to obtaining a sanitary permit Note: Application forms for sta[eowned POWTS are �y �e U1 ew <br /> submitted to the Department of Commerce. Personal Infommation you provide may be used for second <br /> ass N accordance witb the Priva Law,a.15. 1)(m),Stats. Protect Address(if dlTerent[ban mailing address) <br /> I. A Pri <br /> Station Information-Please nt All Information <br /> Property Owner's Name <br /> .57'V11V I'Vclo, W/sr/ Parcel U7-o31ne141-/G-33.3 <br /> Property Owner'a Mailing Address 03 -000- 0 1 f `.Z•C)c <br /> Property Locatirn <br /> city,stile at , Pxe,f $£''9',SF 64 <br /> Zip Code Phone Number <br /> SdM Yrs g( <br /> 44.1 z— S y0d r — 0 v, 5W v., Section 33 <br /> IL Type of Brtilding(check all that Apply) T yl (crtcle one) <br /> Pp Y) Lot# N; R /F•/7Eor® <br /> I or 2 Family Dwelling-Number of Bedrooms �i <br /> K Subdivision Name <br /> ❑PubadCommeteial- Block# <br /> Describe Use <br /> ❑ <br /> Some City of <br /> Village <br /> Owned-Describe Use CSM Number -1-- <br /> ❑Village of <br /> H3Sy <br /> ype ��29A 1lb� Town of S r+r/JJ <br /> III.Tof Permit: (Check only one boa asn Zine A. Complete firma B if applicable) <br /> A. �r <br /> .61 New System ❑Replacement System <br /> Treatmrnl/Holding Tank Replacement only ❑ Other Modification to Existing System(explain) <br /> B' U Permit Renewal 0 Permit Reviion <br /> Before Expiration U Change ofPlumber 0 permit Transfer m New List Previous Permit Number and Date Issued <br /> IV.T e of POWTS stem/Com onent/Device: Check an that apply)Owner <br /> *9Non-Pressurized In-G.-d 0 Pressurized In-Ground 0 At-Grade <br /> ❑Mound>24 in.of sortable soil 0 Mound<2q in.ofauhable soil <br /> 11 Holding Tank ❑Other Dispersal Component(explain) ' <br /> V.Dis ersanTMahnent Area Information• 0 Pretreatmrnt Device(explain) <br /> Design Flow(gpd) Design Soil Application Rat <br /> .?& O e(BPdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> y3� <br /> VI.Tank Wo 4dTCapacity in ��•D <br /> Total #of Manufacturer <br /> New Tanks Gallants Gallons Unita ,y c <br /> Exiting Taiks <br /> Septic or Holding Tank b w m <br /> t V y y <br /> Dosing Chamber aeo Ire 14 i s�.7w Y iL <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(PrmQ <br /> J' Plumb"'a Signature <br /> R fG/G /�p/0%r n J M <br /> 1R/ <br /> ,MFRS Number Business Phone Number <br /> Plumber a Address(Street,City,Snte,Zip Code) Ji4(`r •/ 7/S— �G- y/,s-7 <br /> o� 77G O hlw 3S" t'f 'e ✓ tvZ— -S3td'9 <br /> rV/III.Court /De admen,Use Ont <br /> 18 Approved U Disapproved Permit Fee Date Issued <br /> S Iseuvi 8i1giiature <br /> 0 Owner Given Reason for Denial 3�J�P 23;rS 21Dl� <br /> IX.Conditions of ApptrovaVRmsons for Disapproval <br /> Atbeh b m®plate plarofor ilia afatem aM auhmN m the Cou oN an <br /> tuY Y paper mt krs thea 6 tr1 a 11 Iiahea'vi arse <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />