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cOmmeree.Wi.gov Safety and Buildings Division County <br /> 201 i W.Washington Ave.,P.O.Box 7162 Burn 2 l`�Seo n s i n Madison,Wl 53707-7162 Sani ary Permit Numbe be£died in-by-Co) <br /> Depart n rrt of Cornmeme 5121013 <br /> Sanitary Permit Application State transactionNomber ( e i <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this fort to the appropriate governmental <br /> unit ° required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary project Address(if different than mailing address) <br /> en in a rdaoce with the Priv Law,s.15. I m,Stats. 44M7'2 4 9 <br /> L A Statim Wormation-Pleam Print AB on ation /rrq MA rl G/G <br /> Property Owcer's Name <br /> �7 Parcel# <br /> �r4at3? 'Pt 300 <br /> Property Owner's Mailing Addrea <br /> property Location <br /> le /,/ <br /> City,Stars Govt Lot <br /> Zip <br /> Code Phone Number yy_/VC, S'y Section 3 3 <br /> W 26SIsa✓ W 548`/$ 7/S &G6 >8`d (cvckoro <br /> IL Type of IIrSBdnrB(&C&all that apply) Lot# T 9'C N, R /r- E nne <br /> ®lor2FamdyDweBmg—NumberofBadmome 01 Subdivision Na me <br /> ❑Pu66dCommercial—Deacnba Uae Bloch# <br /> D Cityof <br /> U State Owned—Describe Use CSM Numbs DVilbge of <br /> Iff Town of J4C/C fon <br /> Ill.Type of Permit: (Cheek only one box on Ibte A. Complete Zine B if appBcahk) <br /> A. <br /> ®New SysWn ❑Raplacemmt System D TreatmenbHolding TankRepbcemmt Only ❑Other Modification to Existing Syet®(esplaiv) <br /> B. 0 permit Renewal ❑permit Revision eofPltrmbcr List Pmviom permit Number and Date Issued <br /> Bafor Expiation D l�a� ❑para Tramfafo New <br /> Owner <br /> IV.TypeofPOWTS hm/Com a VDevicr• Cheek an that apply) <br /> ®Non-prmsmrzed la-Ground O Pressurized l"Ground D A"Gende ❑Mouod>2A in.of snaabIesoil O Mooed<24 is of suitable soil <br /> O Holding T=k D Other Dispersal Componeat(Wism) D Pretreatment Device(expbm) <br /> V. aVFreahmeat Arra Wormatim: <br /> Deign Flow(gpd) Des go Soil Application Rste(gpdst) Da <br /> 3 C 0 Penal Area Requced(at) Dispersal Area Proposed(st) System Elevation <br /> 600 bop q <br /> VL Tank Wo CAP i�ty in Total #of hyWnu a• 90 <br /> Naw Tank Tdu Gallons a y4 J <br /> c� s <br /> Septics Holding Tads <br /> Dosing C9rmber QCO / -'S�^ <br /> VIL <br /> Phu Responsibilitym (Print) <br /> Statement-I.the undersigned,amnme rmporsibllity for iortallalioe of the POWTS ahown oa the attached plana <br /> Plumber's Name(Print) Pmmbra's Signature MP/I M Numbs <br /> Bossism Phone Nbs <br /> um <br /> Aomba's Addrem 3 4z •r <br /> v/J�Se / YiS—$bb--C//S-7 <br /> ( troel,City.State,Zip Code) <br /> d 7760 ,tl �s w¢6s><r� w1 s9 3 <br /> VII cam /Laranent U=f�D..d <br /> Approved mvmiit/F,ee` Date Isssued Issuing Sigmtum <br /> Givv(/(/� <br /> IX.Cmdltiona of APPr'm'wxeaaao for Dbapproval <br /> Attach te empMtr pram tar the systems and ru6aa is the County ody m paper rat b t6ana vt:ti toehe b etre <br /> SBD-6398(R.01/07)Valid ibm 01/09 <br />