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cCf wnerCe.wl.gov Safety and Buildings Division County U? <br /> a 201 W.Washington Ave.,P.O.Box 7162 "en Q f <br /> i seo n s i n Madison.W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> wwrtment of corrsneree /�U/ 6.2 <br /> 3 <br /> Sanitary Permit Application State Transaction Need" <br /> In accordance with s.Comm.8311(2),Win.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application form for state-owned POWTS are Project Address(ifdifferent Wan mailing address) <br /> subverted m the Departmsmt of Courmere. Personal information you provide may be used for secondary <br /> purposes in accordance with the Priv Law,a.15. I m,Stats. <br /> L Appthan htf oration-Please Print AB Information <br /> Property Owner's Name Parcel# <br /> John S lo-sfre- 3223-1 032 baa <br /> Property Owner's Mailing Address Finnerty Location <br /> 5-0121{' X41 t /4ve s. Govt Lot <br /> City,State Zip Code Phone Number <br /> Al t Y« .V E Y« Section .4 9 <br /> (f MAI. SS H/ 7 (circle oro <br /> IL Type of Building(cheek all that apply) Lot# T-�—N; R_Jin_E o(0 <br /> ®lor2Family Dwelling-Number of Bedroom 3 Subdivision Name <br /> Block# <br /> ❑PabBdCommereial-Describe Uae <br /> ❑City of <br /> El state owned-Describe Use CSM Number ❑Village of <br /> -die 97 <br /> uTownof f'— <br /> III.Type of Permit: (Check only one box on fine A. Complete line B if applicable) <br /> `L ❑New Systan ❑Replamseut <br /> System �Treatm®tEiaWing Tack Replacement Only ❑Other Modification W Existm8 System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Lml Previous Permit Number and Date Leued <br /> Before Expiation Owner <br /> IV.Type of POWTS stem/Com ent/Device• Check all that apply) <br /> O <br /> ❑Nor-Presnm¢ed In-Crmund ❑preesumcd Lr-Ground ❑At-Caade ❑Mined->24 in.of suitable sor7 ❑Mound<24 in.of suitable soil <br /> ❑lfoldiog Talc ❑OWerDisperealComponent(explain) ❑Preteatmmt Device(explain) <br /> V. aVTrcamrent Ara Wormatlon: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Disposal Am Required(et) Dispersal penal Am Proposed(5-t) System Elevation <br /> V1.Tank Wo Capacity in Total #of Mamt&ctr <br /> Gallon Gallons Unita ° u <br /> New Tardy bd-sTsnh CCk R67 b <br /> 5-`P°`or Rntdirg Tvdc <br /> Doing Clamber <br /> VIL Rapornalbllily Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana <br /> Plurber'e Name(Print) Plumber's Sigoat rn MP/b1PRS Nuvrber Bnsinnse Phorn Nurber <br /> Pe-" _-p �e(s9s—/ lis- X66- Z//,9-T <br /> Plumber's Address(Street,City,State,ZIP Code) <br /> j 776 d e <br /> VII Coon /De artment Use <br /> Approved ❑Disapproved PermtFa Date]Issued Issuing igmtore <br /> 11 Own.GivaaR.for Daniel S �✓0� I U 3aile 6 <br /> DL Conditions of Appreval/Rensotm for Disapproval <br /> Allaeh ase mplete plan far the system and mhmt to the Cwosy miyon napes ma hem Woosto xIlIrchm tedie <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />