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COinmerce.W1.gOV Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 (� n e Yr <br /> iseonsin Madison.W153707-7162 Sal' P it Number(to be filled in by Co) <br /> Daparhnurtt ed Commarca 9 4 <br /> Sanitary Permit Application ShteTmna Number �.l <br /> In accordance with a.Comm.83.21(2),Was.Adm Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application forms far state-owned POWTS are project Ad e(ifdifferen[then mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> sea in aecordsnee with the Priv Law a.15. 1(m,Stats. <br /> L Application Information-Please Print All Information a edem <br /> Property Owner's Name <br /> pBtCel# O o 905ce/Sob <br /> /Data S;ss e -020- -do b-o3-5 -too-cy <br /> Property Owner's Mailing Address <br /> Property 'm <br /> i '7/0 Tie,! c„� <br /> City,stateGovt Lot Zip Code Phone Number Yy Yy Section 3 <br /> EXGC�•frB r In/1/ .5`533 1 951 - 470-S96 <br /> o <br /> T '7'49R /6 B <br /> (cycle o <br /> t appne <br /> tIpL Type of Building(check an thaly) Lot# <br /> q 1 or 2 Family Dwelling-Number of Bedroom 41 SubdivisionN me / <br /> Block# <br /> ❑ <br /> Public/Commercial-DescribeUse • ff--Ft// <br /> ❑City Of <br /> — <br /> State Owned-Describe Use CSMNumber ❑Village of <br /> ffrTe.of eIQK 4q nee <br /> E.S <br /> it: (Cheek only one box on lute A. Complete line B B■ppllabk) <br /> tem ❑Rpbeenent System ❑Treatment/HobiingTaokReplacememOnly ❑OtherMoenewal ❑permitRevision ❑ChangeofPlumber ❑permit Transferb New Listprmiom 't Number act Date Issued <br /> atim TS erkm/Cam ertt/Devke• Checlt an that a <br /> ,W Non-Pressurized In-Ground ❑Pressurized In-Oround ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<2 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pre1r tmmt Devitt(explain) <br /> V. aVfraa�mt Area Wormation: <br /> Design Flo(gpd) Design Soil Application Rate(gpdat) Dispersal Area Required <br /> (/ O ' 7 �s� (st) Dispersal Area Proposed(at) System Elevation <br /> Sb 1:✓ 9y�( les.J• <br /> VL Tank Info Capacity in TOW #of Manufacturer <br /> New Trade, <br /> Gallom Unita ley c,g O <br /> Exivtigg Tmks S U <br /> A. A $ 3 <br /> ti m A ii 5 M <br /> Septic a Holdirg Tads /�OQ <br /> fbang(:Feml+er //'O tl <br /> 7.�0 7Tv <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POVM shown on the sit=led plans. <br /> Plumber's Name(Print) plumber's Si fere <br /> R <br /> 1I 7�� �� /1 /, MP/Iv1PR$Number Business Phone Number <br /> /I tG�G /76 ki hS / s..6' lY �l•S�S/ <br /> Plumber's Address(Ssmet,City,State,Zip Code) '7/S�G/' r!/S 7 <br /> t)t-77010 fd, - 3S 141e6sY*er ! zr-_5' 94? <br /> VIII.Cairn /De artment Use Onl <br /> Approved ❑Disapproved Permil Fee Date Issued Isaumg Signsmre <br /> S (� n <br /> 11 Owner Given Reason for Denial � 8 b I <br /> IX.Conditioner of Approval/Reaman far Disapproval - <br /> AWchb tosspkh pls®(err sex eyah�aod meds bike COuay,mty os paper list less then a M all irchain iu <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />