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eommerCO.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 r&I e /—,f <br /> 'Wisconsin Madison,W 1 53707-7162 Sanitary Penn t Number(to be filled in by Co.) <br /> eparttnem of Commema 4F&,52-7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Cannot.63.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental ��— <br /> unit is required prior to obtaining a sanitary permit. Now: Application forms for state-owned POWTS are Project Addre is(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's No a Parcel# <br /> � I'�� rSr, .,J �, d /�l 906 6o lel �v <br /> Property Owner's Mailing Address 1 Property Loca ion 1 <br /> 3 4;2 3 6) Tit m p' /, � ti!J e-r C_t Govt.Lot <br /> City,State Zip�Coode Phone Number %, 14, Section <br /> Ge, <br /> r •�N !.J (� S /j Q / _(circle ones <br /> Il.Type of Building(ch ck all that apply) Lot k T 33 : R /J E mW-) <br /> Ativision m <br /> or 2 Family Dwelling-Number of Bedrooms Subd <br /> Block q <br /> ❑PubbrJCommercial-Describe Use _5fy 1 <br /> El City of <br /> ❑State Owned-Describe Use CSM Number El Village of_ <br /> IDL Type of Permit (Check only one box online A. Complete line B if applicable) <br /> A. 0 New System D Replacement System 0 Treatment/14okling Tank RePlacement Only D06"Modification to Existing System(explain) <br /> I <br /> B. DPermit Renewal O Permit Revision O Change ofRumber 0 Permit Transfer to New List Previous it Number and Dale Issued <br /> Before Expiration Owner 'n:100S02 <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that a 1 <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in of suitable sod 0 Mound< in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) _ _ 0 Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> S <br /> V1.Tank Info Capacity in Total W of Manufacturer yy <br /> Gallons Gallons Unita y y °o -8 0 <br /> New Tanks Fxkting Tanks v e �b n <br /> d:v H & <br /> Septic or Holding Tank Cj o CIO <br /> If <br /> Dosing Chamber e5 D &O <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation ofthe POWTS shown on the art ched plans. <br /> Plumber's Name(Print) MPIMPRS Numb Business Phone Number <br /> eli Plumber's Signature lFu�'lo�i� u z ,2276 9 Sys —7�SSG <br /> Plumber's Address(Street,City,State,Zip Code) -I— ,/ <br /> Vill.Coun /De artment Use Only <br /> P! Approved 0 Disapproved Permit Fee <br /> Date Issue�d� Issuing A gaeture <br /> 0 Owner Given Reason for Denial S /wgy !d4e. o7 <br /> IX.Conditions of Appir"SURe.-seas oval <br /> VevlFy' mar THE 6;e157o,,c, Aafl) TAX- 7TleT -rl4(5 T K As imigrS 6o is <br /> t ►ytw As P6, SAMT44d /kP*r #- 288803 Cao 20) Awos. <br /> Atlarh m rompetr ptam for tM ayrtem and submit to Ibe County.dy un paper mt ten dun a is a li 1. In sire <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />