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CORIRterce.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 L' <br /> isconsin Madison,wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ff <br /> Deparanerit of Comrrrnroe -1{8lv lv 35 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Conan.83.21(2),W is.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 aro Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> sm in accordance with the Privacy Law,s. 15.0 1 m,Stats. jJ <br /> I. Application l0'0 runtion-Please Print All Information (p'7,51 R96 9 ,p040 110Ab <br /> Property Owner's Name Parcel#n7ro/d•d'39'� '17'�f o2•vew•o17onD <br /> A 1i A- ©!8 33a o a goo <br /> Property Owner's Mailing Address Property Location <br /> 60� 69 Y6 <br /> City,State Zip CodePhone Number Govt Lot <br /> 11JW SC �, Section�z <br /> — LL � <br /> TN. RE or <br /> II.Type of Building(check all that apply) Lot# <br /> >44r 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# — <br /> ❑PubliclCommercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of <br /> BI.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑ New System y �(Beplacement System ❑Trealment/Ilolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <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 tem/Com onent(Device: Check all thatapply) <br /> 1Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area R Riled s Dispersal eq ( f) Area Proposed(sf) Synem Elevation <br /> b0 15 /ao /'0200 G <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Turks Existing Tanks <br /> rXU ti „ wV 0.. <br /> Septic a Holding Tank o 7sa 00 D <br /> Dosing Chanlxa O� C-/YI G. (.v L ,p4— <br /> VII.Responsibility Statement- 1,the undersigned,asaame responsibility for installation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> Ade r%3 Ao/ � az zG 9/ C2 y '-7 z96 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -L'-0�0x5S-�Y5; e .J - 7a <br /> VII .Court /De altmeot Use Only <br /> Approved 11 Disapproved Permit CFee D!a�te Issued Issui Signature <br /> ❑ Owner Given Reason for Denial S 2JO eC.U•S 07 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atbch to complete plans for the syahm mud submit to the County Rally on <br /> taper not Ira than 8 12 111 mehn in sift <br />