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oor[rmeroe.wLgov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 4 /`/kJ 2. <br /> is e o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce J 51 1 <br /> Sanitary Permit Application Show Transaction Number <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental VIU'! e 1 P+t_J vV <br /> unit is required prior to obtaining a sanitary permit Note: Application form for state-owned POWTS are Project Address(if different th'an�m/ailing addd a <br /> ma ) <br /> submitted to the Department of Commerce. Personal information you provide y be used for secondary ` <br /> �`�'00 3 Sf} I k ]/r <br /> purposes in accordance with the Privacy law,s.15.04 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Own r' Name -�g-)� //�1 �71�7 Parcelft C7 - esl�- <br /> �l'��! r7 W" 2.--Zt� l .SOJA-C90 �J�O[�ci) <br /> Property Owfier'sj&iling Address Property Location <br /> 7 c- Govt.Lot / <br /> City,State Zip Caere Phone Number yy., Section oe 7 <br /> 3 <br /> (circle one <br /> LII-.Type of Building(check all that apply) /O� Lot# •� T�Q_N; R E a W� <br /> 7'Y or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> OeF Block# .— <br /> ❑Public/Commercial-Describe Use <br /> ❑CiTy of �— <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> v1a ya ��lbwnof�� <br /> HI.Type of Permit: (Check <br /> tt only one box on line A. Complete tine B if applicable) <br /> A. ❑New System xrReplacement System g p y g y (explain) <br /> y El Tank Replacement Only Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onentlDevice: Check all that apply) <br /> 9""Non-Pressurized In-Ground ElPressurized In-Ground ElAt-GradeEl Mound?24 in of suitable soil ElMound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Ares Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> /SO . -7 ca l-r 1�? S d &--5-0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ci „ y 2 <br /> New Tuoks Existing Tanks m <br /> i U o0 in ii V a <br /> Septw,n en d _ �S G rrtG_ 7L <br /> Dosing Clamber <br /> VII.Responsibility Statement-I,the undersigned,Somme responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature IMP/MPRS Number Business Phone Number <br /> ZJ d � �',��S�o% < zz767/ 3 - 9 -7.286 <br /> PIer's Address(Sneer,City,Stare,Zip Code) <br /> 4 �l <br /> 70 ,Y _5-/ 1y s, e"e tom) �J 4 jl3 <br /> VCoun Ne arlment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing A ignature <br /> ElOwner Given Reason for Denial E 2 5� 3 J ult 20Y <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8I x 11 inches in size <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />