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commerce.Wl.gov Safety and Buildings Division County <br /> a 201 W.Washington Ave.,P.O.Box 7162 Qµroma d 7 f <br /> i seo n s i n Madison WI 53707-7162 Sanitary496 <br /> Pa it Nu'mbeer,(to be filled in by Co.) <br /> Department of Commerce `-f'8 5471/ <br /> Sanitary Permit Application Into mussel ion Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental _1— <br /> unit is requited prior to obtaining a sanitary permit" Now: Application forma For state-owned POWTS are project Add a(if different than mailing address) Ji <br /> submitteed to the Department of Commerce. Personal information you provide may be used for secondary (� t <br /> purposes in accordance with the Privacy Law,a.15.04(1 m),Stab. �(.f <br /> L Application Intonanation-Please Print All Information J1773 A"0SY40U&2'(' f'- <br /> Property Owner's NamePam(# <br /> ✓e a fern 'C.aW a3p as-coo <br /> Property Owner's Mailing Address Prop,Lou cm <br /> 11 77-T R^".J G4Nelr rr fid• Govt Lot <br /> City,State Zip Code Phone Number 1W Y 6✓ / <br /> y Yc, Section <br /> Own 6a,.+ Y err -st/83p (circle me) <br /> IL Type of Building(check all that apply) Lot# T `// R/G-01 E odyn/ <br /> 10 l or 2 Family Dwelling-Number ofBedmoms SubdivisionNamc <br /> Block# <br /> ❑Public/Commetcul-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of f r✓/Jt <br /> IIL Type of Permit: (Check only one box on time A. Complete fine B if applicable) <br /> A. New System ❑ <br /> cp Y Replacement System ❑Treatmenf/Holding Tank Replacement Only ❑ Other Modi Fication to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Rev®inn ❑ eofPlumber List Previous it Number and Date Issued <br /> Chang ❑Penrod Transfer to New <br /> Befom Expiration Owmer <br /> IV. a of POWTS S tem/Com anent/Device: Check all that a <br /> 4MNen-Pnsamized In-Ground ❑Premunzed In-Groin ❑ At-Grade ❑Mound>2A is of suitable soil ❑ Mound< in of suitable soil <br /> ❑Holding Tank ❑Other Disposal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersalfIrmatinerit Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(Welsf) Dispersal Area Requued(st) Dispersal Area Proposed(of) System Elevation <br /> 41f S' , S 900 700 9y• r <br /> VL Tank hdo Capacity in Total #of MarmGcturr <br /> Gallons Gallon Units a g A <br /> New Tusks Eziaurg Tamils <br /> Septic or Holding Tank /OdIO /0e0 <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the afted plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> I2tc/c rS/o krn> /�,u�-�c7 <br /> Plumber's Address(Sleet,City,State,Zip Code) <br /> X7760 WebSfr� t✓S S�lef93 <br /> VII Coun /De artorent Use Onlyi <br /> Approved ❑D®approved Permit Fee Date Issued Iasuvrg em tare <br /> �) a <br /> ❑Owner Given Reason for Denial <br /> DL Conditions of Approval/Reas am fee Disapproval <br /> Attach to eoaptete plain for the ryrtess and submit W the County only as paper rest res thus 8 I x 11 Inch=I I sin <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />