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Commerceml.gov Safety and Buildings Division County <br /> 201 W,Washington Ave.,R�,BOX 7162 43t^rrt 'CIf` <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled m by Co.) <br /> Department of Commerce 540 3 Q 7 <br /> Sanitary Permit Application StatteTra 6 Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form m the appropriate governmental <br /> unit is required prior m obtaining a sanitary permit Note: Application forms for sfateowned 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 /> 22joscs in acwtdance with the Priva Law,s.15.04(1)(m),Stats. <br /> L Application Information-Please Print All Informatio <br /> Property Owner's Name Parcel#07-d <br /> H."a M $.h(e 3(.'1-(0.17-23.5aS�L GCI00D <br /> r 036 4Y4}3 O/ y00 <br /> Property Owner's Mailing Address <br /> Yf!4 Property Location <br /> Go <br /> City,State Govt.Lot LYb a F if 1714 U. <br /> Zip Code Phmne Number 3 <br /> yq Yq Section '1 <br /> 04Mbur) WS .S'q 83D (cycle one <br /> IL Type of Building(check all that apply) Lot# T y0 N; R i 7 E or <br /> � <br /> Q l or 2 Family Dwelling-Number of Bedrooms a Subdivision Na me <br /> Block# <br /> ❑PublidCommercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number El Village of <br /> ® Town of G n I t h <br /> III Type of Permit: (Check only one box can line A. Complete line B J appBcable) <br /> A. ❑ New system y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ® Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Chan eofPlumber List Previous Permit Numberand Date Issued <br /> B ❑Permit Transfer to New <br /> Before Expiration Owner 301 <br /> (OQ C <br /> IV.T e of POWTS S stem/Com onent/Device: Check all that apply) o! o <br /> -N Non-Pressurized In-Groand ❑Pressurized in-Gmuod ❑At-Grade ❑Mound>24 in.ofsuitablesoil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersayrMatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Arca Pro <br /> 34 Per posed(at) System Elevation <br /> ti1.7 yTJ cj r 3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallows Gallows Units o a <br /> New Tanks Existing Taolrs a <br /> u c d � b <br /> cC V h �' y iv <br /> Septics Holding Tank ypp goo <br /> ttrb <br /> / S/c•W X <br /> Dosing Chanter <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/Iv1PRS Number Business Phone Number <br /> /pec /r/oPler.1 iZ.-..1..+✓� �� atAI1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a-77jo N 3r webtsr. it r s.t <br /> VIIL oust /De arhment Use Onl <br /> Approved ❑Dian novel Permit Fee Date last <br /> IasuingA (urs <br /> ❑Owner Given Reason forDenial E 325 �'✓fat'�b <br /> IX.Conditions of ApprovaMeasm,for Disapproval <br /> Soi! Hslr 1ndrGs[c 3996 - 6NI Sr,A. <br /> Attach rs soapiest plass forth system and submit tothe County only as paper not less than 8 rm s 11 Intra last. <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />