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commerceml.gov Safety and Buildings Division County <br /> 201 W.Wasltington Ave,P.O.Box 7162 <br /> isco n s i n Madison.Wl 53707-7162 Sanitary Permit Number(to be filled in by C.) <br /> Department of Commerce Ln/^ 453 <br /> Sanitary Permit Application State Tcan�aa ..N.aabbc <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental y�r Lek) <br /> unit is required prior to obtaining a sanitary permit. Note: Application fors for state-owned POW TS are Project Address(if different than mailing'address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> EuToses in accordance with the Privacy Law,s.15.04(i)(m),Stats. 9hr y LO .�e'/� <br /> u <br /> I. Application Information-Please Print AB Information <br /> Property Owner's Name P--I# p7-O1 D•6'�/D r 'd0•,$' <br /> Jtm, Ce^b-c&' 1$-461 -VA 30,60 <br /> Property Owner's Mailing Address <br /> Property Location <br /> SSsy'4, 1.PG11 MA rt 4 — /vE <br /> swbi.at <br /> City,State Zip Code Phone Number Section 124, <br /> Alb-re•fvi Ile j✓7Al .8'5301 T 00 N; RAE on� <br /> IO <br /> IIL•Type of Building(check all that apply) Lot#1 or 2 Family Dwelling-Number of Bedrooms 3 /3 <br /> Subdivision Name 0 , / Je p `l I, <br /> Block /-4 PLA wr- r. VI err' tjw'/ . <br /> El PubadCommereial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number r❑1 Village of <br /> LS Town of 0e./'C/w-use- <br /> I IL Type of Permit: (Check only one boa on line A. Complete fine B ff applicable) <br /> A. Q New System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing Syslan(explain) <br /> B. ❑Permit Renewal ❑Perit Reviion ❑Change of Plumber ❑Permit Transfer to New Lis[Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> S Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ Al-Grade ❑Mound>24 in.of suitable sod ❑ Mound 124 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. . ersaVrreahncut Area Information: <br /> Design Flow(gpd) Design Soil Application Rne(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sl) System Elevation <br /> 413'•0 . 7 G y 3 6 4 g 90. 70 <br /> VI.Tank Into Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New TanksExiting Tanks 4A u i5 o C W is <br /> Septic or Holding Tank <br /> Dosvg Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation or the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rr a/c <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,A77( G //—y 3S bvebsyce- W2�S Y Srl3 <br /> VIII.Cozen /De artment Use Ont <br /> El Approved ❑Disapproved Pcmuit Fee Date'I/ssuedqq'��� Issuing ignature <br /> ❑Owner Given Reason for Denial S 3 2 5�'4 �&A�WJ <br /> IX.Conditions of ApprovaUReasoro for Disapproval <br /> Attach m complete Plum for dw system and submit to the County osdy m paper not ka than 8 In x I I inches maize <br /> SBD-6398(R.01/07)Valid tlrru 01/09 <br />