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eonwnereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> iseonsin Madison.W153707-7162 Sanitary Permit Nu irbertt.be filled in by Co.) <br /> tDopwrtneent of Commerce 5,22 ) O <br /> Sanitary Permit Application State Transaction umber <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS we Project Address(if Ifflemm than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary purpoon UJ` 1 <br /> in accordance with the Priv UJ <br /> Law,a.15.04(Ixm),Slats. <br /> 1. Application Information-Please Print All Information <br /> S �tP �aWh l]✓. <br /> Property Owner's Name /� Parcel# <br /> to W �,4 o/a-`I6 5'&oTJ'od <br /> Property Owner's Mailing s Property Location <br /> /17&/3' E tef RA Govt Lot 61 <br /> City,State Zip Code Phone Number <br /> Yy %y Section <br /> FA.-r+/n /onSSO yI y (oS/ 3yH- F7/g (circle one) <br /> T�O N; R /.f"- E or� <br /> IL Type of Building(check all that apply) Lot# <br /> �.1 or 2 Family Dwelling-Number ofBedomme 3 Subdivision Name <br /> Block# a <br /> ❑Public/Commercial-Describe Use <br /> 0 C' of <br /> El State Owned-Describe Use CSM Number ❑Village of <br /> IRTowns of K de n <br /> III.Type of Permit. (Check only ane box on lime A. Complete line B S applicable) <br /> A ®New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modificat an to Existing System(explain) <br /> H. ❑Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber 0 Permit Transfer to New List Previous Penn' Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS stem/Com onent/Device: Check all that apply) <br /> M Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Code 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Componeut(explain) 0 Pretreatment Device(explain) <br /> V.Dispenallrrmannent Arm Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Ares Required(at) Diepmal Area Proposed(at) stem Elevation 9SUp ON" <br /> Z/SO . 7 /0 y 3 a elle 3.70 4" <br /> VL Tank Wo Capacity in Tons l #of Manufacturer <br /> Gallons Galloon Units y t)3 <br /> New Tanks fsxxisting Tanks A 3 to y <br /> cC 01 <br /> Septic or Bolding Tank /ado <br /> Dosing Chamber <br /> V IL Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the aftacha pians. <br /> Plumber's Name(Print) Plumber's Siggnature MP/MPRS Number Business Phone Number <br /> 7/G/l Am lC/N f /?W- .con' /4 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 //w3S t f/abs�rr GI/ Sal g9 3 <br /> VIU.Cam /De artment Use Only <br /> Approved 0 Disapproved ReasonPerron Fee Date Issued �� Issuing Srgramr; <br /> a � <br /> ❑Goner Given Reason for Denial � IJV <br /> IX.Conditions of Approval/Ressons for Disapproval <br /> Mach to complete pnnsfar she system and submit Isthe Comedy only oro paper not W than A in x 11 Inches In sh <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />