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eommereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 r � <br /> iseonsin Madison,Wl 53707-7162 Sanitary Permit Number(In be filled in by CuJ <br /> Department of Commerce 51Z <br /> / / <br /> 5-4 <br /> Sanitary Permit Application State TmnsactionNumber (� <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 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 -L- <br /> purposes in accordance with the Privacy Law,s.15.04(i)(m),Stats. / s <br /> I. Application Information-Please Print All Information r� 770171,n ee ver e!q.ny/hf <br /> Property Owner's Name /' Parcel H �! / <br /> Tlfr l /.3avY'e// �Tl.#� L�� 0301 9diS- od ooh <br /> Property Owner's Mailing Address <br /> Property Location <br /> Ci State Govt Lot <br /> City, Zip Code Phone Number - <br /> Yy Section 3S <br /> SSO(ll /a Sl- JN e/- 67y!70 (circle one) <br /> it.T e of Building check all that apply) T 411 N; R 16E of67 <br /> YP g( PP Y) Lot# <br /> JR I or 2 Family Dwelling-Number of Bedrooms 3 /O Subdivision Name <br /> Block9 MANLC&) ACRES <br /> ❑PublidCommercial-Describe Use <br /> ❑ City of <br /> ❑state Owned-Describe Use CSM Number ❑ Whigeof <br /> ® Town of ,f...rJ1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New system �r <br /> y SOI Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision El Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dale Issued <br /> Before Expiration <br /> Owner <br /> IV.Type of POWTS S stem/Com onenuDevice: Check all that apply) <br /> 2 Nun-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 1..of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flu.(gpd) Design Soil Application Rate(gpdsB Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> giro -7 6,4i/3 G4e6 93.s� <br /> V I.Tank Into Capacity in IOU] a of Manufacturer <br /> GallonsGallons Units yy o <br /> New Tanks Dx t TaTanks -e <br /> o .• � ,ou, �= m <br /> m wc7 4 <br /> Septic a Holding Tank fl:U i7 <br /> /Oo 0 <br /> /'P'O <br /> Dasng Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation orthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> /z/c% ffo /✓i., 1 / ufr�,�Q26/1-'!/s-7 <br /> Plumber's Address(Street,City,SGte,Zip Code) <br /> 7760 f/ � 3S wt6sfr� Lvr S5 8S 3 <br /> VIII.Coun /De artanent Use Orel <br /> Approved I ❑DisapprovedPermit Fee Date Issued/��7 Issuing gent Sigynatturre <br /> ElOwner Given Reason for Denial S kO- _3_�`� 7 I I ('7-) <br /> M Conditions ofApprovaVRemmus for Disapproval <br /> Attach to complete plans for the system sud wbma to the Courcy only an paper nct les Nan a in a 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />