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Safety and Buildings Division County <br /> / <br /> ;- lvk, 201 W.Washington Ave.,P.O.Box 7162 A.,r/7-e <br /> 110, 1% SN. Madison,W( 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> 5512 12 <br /> Sanitary Permit Application state TnN/umber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmmn...— Ou-' / Rev I e(A) W <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if diffie ent than mailing address) C) 1 <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary �/ <br /> purposes in accordance with the Priv Law,s. 15.04(l m,Stats. 4 fin e Df <br /> 1. A lication leformatan-Please Print All Information <br /> Prope Owner's Name Pa cel# <br /> f F r� e/. %o r//3 s ds oat aw <br /> Property Owner's Mailing Address Properly Location 5 ll.%A, Fxeelt', Al*0, <br /> 6 e D / � ., Govt.Lott - <br /> Ciry,State `� Zip Code /' Phone Number _ys _y,, Section <br /> .1 1 Z��L/ �1qcircle one), <br /> 1IL Type of Building(check all that apply) Lot# T ly N; R E or✓71 <br /> 1 or 2 Family Dwelling-Number of Bedromns Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number 11 Village of <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if applicable) nQ _ _ - <br /> A. ❑New System Replacement System ys[e ❑Treatment/Flolding Tank Replacement Only [I Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> ttcV.Type of POWTS S stem/Com ownetWevice: Check all that apply) <br /> W Noo-Pressunzed In-Ground ❑Pressurized In-Ground ❑APGrade 0 Mourd>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVIrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 2�0 9?0 i <br /> VI.Took Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 0'3 0 <br /> New Tanks Emsnng Tanks v 2 .9 u $ <br /> a <br /> J.U in � N w <br /> Setroc or Holding Tank / Ys <br /> [losing Chamber <br /> VII.Responsibility Statement-1,the undersigned,ausme,responsibility for installation of the POWTS shown on the attached plow. <br /> Plumber's Name(Print) Plumber's ign WIMPRS Number Business Phone Number <br /> i� <br /> PI 's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De rtment Use On <br /> Approved ❑ Disapproved Permit eeei��j_ Date Issued '` Issuing Age e <br /> ❑Owner Given Reason for Denial :t4$�ou�'^s+ ,Gall/ <br /> IX.Conditions of Approval/Reasous for Disapproval <br /> Attach te complete plans for The system and submit to dre County a*an paper not tar than a LS 111 inch"in Are <br /> SBD-6398(R.10/11) <br />