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COfDIDBPCB.WL90V Safety and Buildings Division Coun <br /> 201 W.Washington Ave.,P.O. Box 7162 qJ <br /> Department Madison,WI 537077162 Sanitary PermitNumber(to be filled in by Co) <br /> Department of Commerce J-2 � 2-7 <br /> _ _ _ __ _ _ _ ----.-.___ <br /> --- — - — - State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with s.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 POINTS are Project Address(if different than mailingaddress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary ,2 lq O(� 7 q x <br /> purposes in accordance with the PrivacyLaw,s. 15.04 I (m),Stats. <br /> I. Application Information-Please Print All Information n, ------ <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> Po -/.a ____ Govt.Lot__._ <br /> City,State Zip Code Phone Numhcr y, '/ Section�Z. <br /> 3 0 303 -os61 ryq {[(circle oncL <br /> 11.Type of Building(check all that apply) <br /> rr�� Sub`I7visan Namc <br /> ( ort Family Dwelling Number of Bedrooms. rRlock4 <br /> A11'h <br /> -_ <br /> ❑Public/Commercial-Describe Usc ___ ------ �- ❑ City ofr ❑ Village of❑State Owned Describe Usc__-__ --_. -.-- - ----- � ,I'own of_ �O` — <br /> III.Type of Permit: (Check only one hoz on line A. Complete line B if applicable) <br /> A ❑New System /4eplacement System ❑TreatmenUl folding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> — hist Previous Permit Numhcr and Date Issued <br /> B. ElPermit Renewal [IPermit Revision ElChange of Plumber 11 Permit Transfer m Nrw <br /> Before Expiration Owner <br /> ------ <br /> IV.Type of POWTS S stem/component/Device: (Chuck all that applyL-_ -__--_ ----- ----- - -- <br /> - - _- _—_ _ <br /> xlNon-Pressurized In-Ground ❑ Pressurized hi Ground ❑At-Cirade ❑ Mound 24 inof suitable soil ❑ Mound<24 in.of suitable sod <br /> ❑ Holding Tank El Other Dispersal Component(explain) __. _.- —_.-- ---. <br /> Pretreatment Device(explain)- <br /> V. <br /> ex Iain)_V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arca Required(st) Dispersal Arca Proposed(S715 System Elevationon' <br /> VI.Tank In Capacity in Total #of Manulaclwcr <br /> Gallons Gallons Units G m „ N to <br /> U <br /> New Tanks Existing Tanks E <br /> N — <br /> Dos ng Cbamber <br /> VIE Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbr's Signature MP/MPRs Number Business Phone Numhcr <br /> e <br /> ,e- a Lio� o,� _ 2z7 ` / y9-ia�"6 <br /> lumber's Address(Street,City,Stale,Zip Code) <br /> V 1.Count IDI artment Use Only -ut — - <br /> --- -- <br /> - <br /> --- <br /> Permit FCC Date issued Isswn gent SignaturepProved ❑Disapproved Srlq- <br /> ❑0 <br /> Owner Given Reason for Denial pp(( 'I- --- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Anech to camplele plain far the system and submit Ia-the only an paper oat less than tl IIx x I1 inches fn sl- <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />