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coffirnerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 B r h C 7! <br /> iseonsin MadtsoSWl53707-7162 Smutary�P tN�er(tobefilledinbyCo.) <br /> Depertrsterd of commerce 4 K, /✓ <br /> Sanitary Permit Application State Transact on Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental •---P� / <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) IVl„1 <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary \ <br /> purposes in accordance with the Privacy Law,s.15. 1 m,Stan. XJ <br /> L ApplicastionWormation-PleasePrintABW3d�ormation 3apMA•J aAb <br /> Property Owner's Name parcel g <br /> 'Jo 401 /,/G4 3003d- sir/9 - otisoa <br /> Property Owner's Mailing Address property 1—.ce <br /> 3 0(93 e?.-^o 4.x Govt Lot r*16 of <br /> city,state zip Code Phone Number si, Y., t✓ Yy section�yiJ� <br /> &Y:— <br /> n64r 'Vet SfI?P30 T y� R (circle V <br /> IL Type of Hnrlding(check aB that apply) rf Lot k - - s� <br /> 191 or 2 Family Dwelling-Number of Bedroom Subdivision-Ruse <br /> Block k <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSMNumber 0Village of <br /> ,o.Town of <br /> IIL Type of Perahitr (Check only one box on line A. Complete tine B ff applicable) <br /> A. ❑New System <br /> �Replacement System ❑Treatment/Holding TadrRepbrcemmt Only ❑Other Modir Mod'kation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Number ❑Permit Transfer to New List previous P ermit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S3 tem/Com essUDevice: Check all that apply) <br /> M Nm-Pressurized ki-Ground ❑Preesunzed In-Ground ❑ At-Grade ❑Mound>21 in.of suitable soil ❑Mound<2 t in.of suitable soil <br /> ❑Holding Tank ❑0therDispersal Compmmt(explain) ❑pretreatment Device(explain) <br /> V. evsaVrreatinent Area Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdef) Dispersal Area Required(at) Dispersal Area Proposed(ef) System Elevation <br /> 3019 7 d/}9 -11311 90-J <br /> VI.Tank Wo Capacity in Total N of Manufacturer <br /> Gallon Gallons Units <br /> New Tanks Existing Tardac b <br /> a u U <br /> S U m ii,C7 y <br /> Septic or Holding Tarok <br /> D=%C amber <br /> VIL Responsibility Statement-I,the undersigned,assume responsib8tty for installation of the POWTS shown on the afta bed plana <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rle-le 0 0/...s .� 13/ obt s Ss-/ sir- Edi-vi.s- -7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d�'7�D „r ?.S' (.v26sfr� w1 Sy X93 <br /> V1JL Conn /De artment Use Ont <br /> Approved �Daapproved Perm/iJt F�x•��7 Date Issued Izeam Signstun <br /> ❑Owner Given Realm fa Denrsl SOS J(// Q / <br /> -/ <br /> IX.Conditions of Approval/Reasona for Disappmval <br /> Match to complete plain for ths system and submit totin County only on paper rot has than 81n s 11 Inches j I size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />