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Ooffirneree.mil.gov Safety and Buildings Division CountyJakob p <br /> 201 W.Washington Ave.,P.O.Box 7162 /,�IA 0 n Q <br /> 'Wisconsin Madison.WI 53707-7162 Sanitary Permit Number(to be filed in by Co.) <br /> Department of commeme 0.2 /_ <br /> Sanitary Permit Application State Tr sac//tion Num//bar U <br /> In accordance with s.Comm.83.21(2),Wis.Adm Code,submission of this firma to the appropriate governmental v+.�C ¢C��(e(� <br /> unit is required prior m obtaining a sanitary permit. Note: Appticatiom forms for soteowned POWTS are Project Addms(if differeat than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> pu2oscs in accordance with the Privacy Law,a.15. 1 m),Stats. <br /> L Application Information-Please Print An Lrformation F6 N 7 66 Rd u <br /> Property Owner's Name Parcel p <br /> /3/ ii sc�„,;tom �o3a� 60,4- 0/& <br /> Property Owner's Mailing Address Property Location <br /> K9 3 O no. n,h rrdr cif GoirtLot -1 <br /> City,State Zip Code Mime Number %., <br /> A3 <br /> /� Y., Section <br /> SY LO N I f PA ✓ r.$ �!/(p (circle one <br /> ILL Type of Building(check allthat apply) I.ot g T y0 N; R >7 E <br /> Xj or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Publie/Comme vial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ry❑Village of <br /> t/1 )p/s-� ry Town of <br /> IIL Type of Permit: (Check only one box on lite A. Complete line B if applicable) ri _ _ _ <br /> A. ❑New System rryy <br /> Y Ja,}<eplacement System ❑TreabmenUHolding Tank Replacement only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change ofPlumber ❑permit Transferm New Lest Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> xI�V.Type of POWTS stem/Com ent/Device: Check all that apply) <br /> p Noa-Prenmized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 is of suffabIc soil ❑Mommd<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(cxplam) ❑Pretreatment Device(explain) <br /> V.DispetsaYfireahnent Area lnformatim: <br /> Design Flow(gp n Design Soil Application Rate(gpdat) Diaper-1 Area Required a Dia <br /> ( t) persal Area Proposed(at) System Elevation <br /> el 7 d"43 Gad' '143 9a•fo 7 ? <br /> VI.Tank Info Capacity inTotal k of Manufsetu er <br /> Gallons Ganom Unita <br /> New Tanks Fixistlng Tw�ks „�+, u <br /> b 4' <br /> Septic or Holding Tank /B00 <br /> Dosing(:hmber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation orlhe POWTS shown on the attached plans. <br /> Yammer's Name(Print)�� Pluralism's Signature MPAIPRS Number Business Phone Number <br /> lC/Gle i It/n J <br /> Plumber's Address(Street,UICY,State,Zip Code) <br /> 7760 ,Mz 3S /�/ebs><�i GtiT S �g93 <br /> VIIL Canal711 <br /> artment Use Only <br /> ApproveDisapproved permit Fee Date Issued Issuing lute <br /> S qy T{ "' <br /> Owner Given Reason for Denial 3 5VA) � .Jill �ro <br /> IX.Condit ms of Approval/Reasoro for Disapproval <br /> Anarh to eoaplate plain for the eysteu and euboH m the Coumy only m paper mol lea than B rrz s 11 Imcha in sirs <br /> SBD-6398(R.01/07)Valid tlru 01/09 <br />