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commerceml.gov Safety and Buildings Division County � <br /> 201 W.Washington Ave.,P.O.Box 7162 ur q.Q7 <br /> i seo n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> t[loperinvant of Commerce <br /> ✓f'7 O O2 <br /> Sanitary Permit Application State T •mnGsacfion Nornberr <br /> In accordance with s.Conus.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental - V <br /> unit is required prior to obtaining a sanitary permit Note: Application form 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 /> purposes in accordance with the Privacy Law,a.15.04(1)(m),Slats. ser Ole <br /> I. Application Information-Please Print All Information _ <br /> Property Owner's Name parcel# 0/2' 4207 - /0 706 <br /> Property Owner's Mailing Address I Property Location <br /> e 9-lei/ se-i 6 e✓ /26(' Govt Lot <br /> City,Stall Zip Code Phone Number yy yy Section_Z <br /> Wobsfe� Wr s4SI93 7/-< AG4— 8'x36 (circle one)_ <br /> IL Type of Building(check all that apply) Lot# T�e O N; R /S� E OUW <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commescial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ao❑ar Village of <br /> ,W Town of JaG/[36h <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applimble) <br /> A. ❑New System XRephtceotent System ❑Treatmmt/Holding Tank Replacement Only ❑Other Modification to ExistingSatan <br /> Y (explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transferto New List previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com ersbVevice: Check an that apply) <br /> ONon-Pressurized In-Ground ❑Axssur zed In-Grund ❑ At-Conde ❑Mound>24 in.of suitable soil ❑Mound<yt in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V'Digpmavrreahnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispaaal Arca Required(at) Dispersal Arco sed <br /> y.S-'O — Proposed(st) System Elevation <br /> 900 Sao <br /> VL Tank Wo Capacity in Tots) # <br /> Gallof MaouGcturer <br /> ons Gallons Units <br /> New Tanks Fjwb gTanks o b m o <br /> yon ti w� � <br /> Septic or Holding Tank /O6B /600 <br /> Dovng Clamber 10-4" <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /Z'ck- Ao 4/c -7/. vis? <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> /7 760 1/ 3S-- Lrl�6S�ar.- �csr SSv 0?3 <br /> VIII.Cassultv/Detuartutent Use Only <br /> Approved 11 Disapproved PearniffecDateIs-sswdIssuing Signature <br /> ❑Owner Given Resson for Denial 8JW <br /> 2,511,/ �y[r`y <br /> IX.Conditions of Appr,o al/Reasons for Disapproval <br /> Arch to tampkh plan for the system and submit tedw County a*on peter not laa than 8 ra all loehea maim <br /> SBD-6398(R.01/07)Valid than 01/09 <br />