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cornmerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> tlepartment sconsin Madison,WI 53707-7162 Sanitaryermit Number(to be filled in by Co.) <br /> of Commerce <br /> Sanitary Permit Application Staterte' action Nummber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (if��Nr, /@ytCts� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS 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 /> u oses in accordance with the PrivacyLaw,s.15.04 I m,Stats. 9 <br /> I. A licadon Information-Please Print All Information <br /> Property Owner's Name .( $ Jr Jr <br /> vf� <br /> Property Owner's fling Address So.J b d a cQ�O <br /> p Property heption <br /> _ <br /> City,State Govt.Lot 7 /� <br /> Zip Code Phone Number <br /> '/-, ''A, Section <br /> v sY83a //J�/Vy cucleone <br /> 11.Type of Build' g(check a 1 that apply) Lot# T N; R -'J E DII <br /> 3r 2 Family Dwelling-Number of Bedrooms 11-7- -- Subdivision Name <br /> ❑ Block#Public/Commercial-Describe Use 1- <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 7Town of j_,jC-SE/J <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable)0 _Q _ 1- 1115-1 <br /> A _ _ _ , <br /> ❑New System ❑ Replacement System ATreatment/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Chane ot'Plumber List Previous Permit Number and Date Issued <br /> Before Expiration g ❑Permit Transfer to New p / nC <br /> Owner /0117 /1,8/10 ,f-9- W <br /> IV- <br /> V.Tv a of POWTS S stem/Com onent/Device: Check all that apply) <br /> �T/ 'f' <br /> ❑ Non-Pressurized In-Ground 13 Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) <br /> ❑Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(s0 Dispersal Area Proposed IJ System Elevation <br /> 0fx,sn W 2 F7- <br /> VLTsunk lnfo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units & e <br /> New Tanks <br /> Existing Tanks <br /> c u g A B <br /> Septic or rldbo=* fb rs U i;i h nib. V 4 <br /> Dosing Chamber S / �- 171�- <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) .I, / Plumber's Signature MP/MPRS Number Business Phone Number <br /> C(jelc� 7 <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> ,B v X I/ ` <br /> VIII.Coon /De artment Use Onl <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing A ni 'gnature <br /> ❑Owner Given Reason for Denial <br /> $3.,7,`00 ,Z !; t o4 <br /> IX.Conditions of ,f provmjKeasods far Disapproval <br /> .S;l A.fQPIf Il qr(,.r .e GryyGelm-rrrCND(1(fl G»r// A44ce.a�l, io T�+al{'EtaNr <br /> �eeN,r So.r.e ys9a+ a8�� <br /> i4am-II IS 7o Re{Alat.e eo0S-&%,4 ,� ( s c 7..14 On N. <br /> Attach to complete plans nor rhe system and submit to the County only on paper not less than s ins 11 Inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />