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oornmeree.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> consin Madison,W153707-7162 N"N <br /> tL�rto—nt of Commence Sanitary Pani(Nomber(to be filled in by Co.) <br /> � as <br /> Sanitary Permit Application State T on N <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form m the appropriate govttamemal <br /> unit u required prior m obhiaing a sanitary permit Note: Application Eons for stateowned POWTS arc , Q <br /> submitted to the Department of Commerce. Personal infonoation you provide may be used for secondary Protect Address(if different than mailing address) <br /> Purlmsea in accordance with the Priya Law,s.I5. 1 m),State. /� <br /> zwwk-o <br /> m Wormation—Please Print ABInformation gib lire,p ie Pp <br /> b NameParcel k <br /> d'c e' � OJen at%S's Mailing Address a / OoS0 Q/ , /C//J ,Sf' Property Location avG aF <br /> Zip Code P1 ne Number 1 Al nl _ _ y, Sectionssio 6 (enrle nateLuilding(chem all that apply) t Lot N T 4/ N, R /b E or v <br /> Sc 1 or 2 Family Dwelling_Numbs of Bedrooms oh Subdivision Name <br /> ❑Publidmm <br /> Coercial_Describe Use Block N <br /> 0 City of <br /> ❑Stam Owned-Describe Uee CSM Number ❑Village of <br /> Town of SW SS <br /> IIL Type of permit: (Check only one box on line A. Complete tine B V apptinble) <br /> A. ❑New Syatem a' O <br /> Replacement System ❑Treatment/HoWing Tank Replacemerst Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision eofPluaber List Previow Permit Numberand Date Issued <br /> Before Expiration �BOg ❑Pttmit Transfer to New <br /> Owner <br /> �I7V.T e of POWTS <br /> w serer/Com ent/Device: Check all that a <br /> Noa-Pressurized la-Ground ❑Pressurized ln-Cmouml ❑ M-Grade ❑Monad>2A in,of suitablesoil ❑ Mound<24 im of suitable soil <br /> 0 Holding Talc 0 Other Diapemal Component(explain) <br /> ❑Pretrsatment Device(explain) <br /> V. ersal/freatment Ares Wormatiac <br /> Design Flow(gpd) Design Soil Application Ra <br /> te(gpdet) Dupenal Area Required(af) Diapttsal Arse Pro sed(� S 6 Da po (sf) System Elevation <br /> 600 9r• <br /> VI.Tstdc Wo Capacity in Total A of Maoufacmrer <br /> Gallons Gallant Unit, <br /> New Tanksa <br /> Exemig Teak.° <br /> Septic or Holduig Tank '�SO 7S0 6 iBno 'R',a <br /> lMv^g Chamber s eQ <br /> -rb0 <br /> VII.Reaporesibitity Statement-L the undersigned,assume responsibility for installation ofthe POWTS sbown on the attached pians. <br /> Annaba's Name(Print) Plumber's Signature <br /> MP/MPRS NambttBusintts Phone Number <br /> h�lc/G �o (/inf / of SSs`/ 7/t_ X66 - y/t <br /> Plumber's Addrece(Street,city,State,zip Cade) Or T <br /> 7760 -? - tvel2s�ri Sf'�r <br /> I ConnffAll)eartmait ere OntApprovedroved Permit Fee Date Issued IuuiAtineGivm Reason for Denial $3.Z5 6 J r g <br /> IX.Conditions of ApprovaVReasona for Disapproval r <br /> Amth to eompkfe plan forth ayaha soil subs mthe CaamY salt'am Aper mat tea Uro 8 trs z it ircM to a4e <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />