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commercemi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 51,1 rl ?-f <br /> jf iseonsin Madison,WI 53707 7162 Sanitary Permit Number(to befilledinbyCo.) ( � � <br /> l7epartmm m <br /> eof Commerce / J-5,� W <br /> Sanitary Permit Application State Transaction_Number U 1 <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 Address(if different lban mailing address) (� <br /> submitted to the Department of Commerce. Personal information you provide may be used for condary -�-- <br /> purposes in accordance with the PrivacyLaw,a.15.04(1)(m),Stats. _ <br /> I. Application Information-Please Print All Information 3 0 i 7J- 7-A a✓ G& l�r. <br /> Property Owner's Name ddr✓ Queer Parcel b <br /> Re,5, /escGl /•cr Ob+' i o3d - -5-J 19 - G &D01� <br /> Property Owner's Mailing Address I&r4 NM(fS 66t-L-t Property Location <br /> l e,k 7 MORA MLl 5565/ Govl.Lot p <br /> City,State Zip Code Phone Number /VW / $tr /, Section ! <br /> Rie e ZAkir (n/i .Sz(576 61 7<S- a 35'- /33 ( circle one <br /> IL Type of Building(check all that apply) Lot N E o t�l' <br /> ®I or 2 Family Dwelling-Number of Bedrooms d' 3 Subdivision Name <br /> Block k <br /> ❑PubbdCommercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 1/01 It, P213 ❑ Village of <br /> 'Town of Sn'z'r3S <br /> HL Type of Permit: (Check only one box online A. Complete tine B if applicable) <br /> A. YNew System y ❑Rephacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Pemril Renewal ❑Permi[Revisiom <br /> ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration owner <br /> II VV.Type of POWTS System/Comp anent(Device: Check all that apply) <br /> a,Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>_24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 300 vas vs� �s <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units Is <br /> Is o$ v <br /> New Tanks Existing Tanks w^ v u _ b g H <br /> m <br /> tCU h � in wC7 W <br /> Septic or Holding Tank :5;�O Q COQ X <br /> S/Go v <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,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 /> �✓c-/c /teoP/C1. S / -�O ��slss lis-8/o6- vis 7 <br /> Plumber's Address(Street,City,Stale,Zip Code) <br /> ) 77Fi e f/ r <br /> VIII.Coun /De artment Use Only <br /> ❑ Approved ❑Disapproved Permit Fee Date Issued Issuing Ag ture <br /> S 300-,49Dpi <br /> ❑ Owver Given Reason for DenialIV <br /> LX.Conditions of ApprovaVReasons for Disapproval <br /> Map�ta ds Graylt n9 Sa.to( -345.8 <br /> Atbch to complete plans for the system and submit to the County only on paper rot less than 81n s 11 imbes Issue <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />