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commereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> i s e o n s i n <br /> Madison,WI 53707-7162 Sanitary P 't Number(to be filled in by Co.) <br /> Department of Commerce $ <br /> Sanitary Permit Application State Transction Number <br /> In 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 forms for state-owned POWTS are, Project Ad ress(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> 2urpoW3 in accordance with the Privacy Law,s. 15. I m,Stater. � II <br /> I. Application Information-Please Print All Information I I C'QopcL <br /> Property Owner's Name <br /> Parcel# <br /> Property er's Mailing Address <br /> Property ation <br /> City,State Zip Code Phone Number coot.Lot <br /> p �(�f l// :{ / '/. '/., Section <br /> f— /. A / 'r 114/11 �7Y/.-1 71� 71e /D 53 circle one) <br /> ttII.Type of Building(check all that apply) Lot# T IVQ N; R EM-W <br /> .t]I 1 or 2 Family Dwelling-Number of Bedrooms�_ / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Numbers ❑ Village f <br /> UO/ / // ; �$/ )OTownof <br /> III.Type of Permit: (Check only one box on Mae A. Complete line B if applicable) <br /> A' ❑New System Replacettj!�t <br /> t/Holdin Tank Replacement Only 8 ep y ❑Other M 'fication to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑permit Transfer to New List Previo Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWTS S stem/Com nent/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Gmde ❑Mound>24 in.of suitable soil ❑Mound 24 m.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(st) Dispersal Area Prouposed(s System Elevation <br /> lAaP <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units =' <br /> o U <br /> New Tanks Existing Tanks V c & V <br /> a U in w rn C7 G. <br /> eaur r Holding Tank <br /> smg Ch <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the at ached plans. <br /> Plum r a Name(Print) Plumb Sn :!14� 1 <br /> MP/MPRS Numb Business Phone Number <br /> Plumb 's Address(S et,City,State,Zip Code) <br /> erek /p/o ft�GC �4� �i5 c gam/ <br /> FPCoun /De artment Use OnlProved ❑Disapproved Permit Fee Date Issued �7 Issuin Agent Signature <br /> ❑Owner Given Reason for Denial S -a�a I s <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plane for the system and submit to the County only on paper not[us than 8 in 111 Inchm In size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />