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commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 l�u r n C 1N <br /> Is o n s i n Madison,W I $3707-7162 Sanitary Permit Number(to be filled in by Co J <br /> Depart em of Commerce -� <br /> SaYlll�c` r1 y Permit Application State IransactionCNNummbber <br /> In accordance with s.Clpmm.83.27(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior (o obtaining a sanitary permit. Note: Application forms for state-owned POWTS we Project Address(ifdiffercm,than mailing address) ' c <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> u uses in accordanceith The Privacy Law,s.15.04(1)(m),Stats. /1 - // 11\\ <br /> I. A Iteration Info atinn-Please Print All Information at S b 63 /3,o z,e .�pt; W <br /> Property Owner's Nam !.� Parcel# o 7 aj dy d YO/ 08 SOS <br /> Geer e rwWr 35,"!3 DOd O/(•ibt9� <br /> Property Owner's Mail' g Addressdlvss Property Location <br /> Govt.Lot <br /> City,State 'Lip Code Phone Number <br /> Section <br /> sLisrewoA /YrN Sr-33( (circle one <br /> II.Type of Building check all that apply) Lot# T N; g o <br /> PP y) I <br /> I or 2 Family Dwell' g-Number ofHedsmens Q Subdivision Name <br /> ❑ # U,4 P/oA PublidCommercial-Describe Use Block <br /> ❑City of <br /> El State Owned-Descriase Use CSM Number ❑Villageof <br /> Town of S4ef7,04 <br /> DL Type of permit: Check only one box on line A. Complete line B if applicable) _ _Q <br /> jA. ❑ New Sys[em �Replacement Sys[em ❑ Treatment/Holding Tank Re placement Only ❑Other Modcafion to Existing System(explain) <br /> ❑PermitRenewed ❑PermitReviion ❑ Chan eofPlumber List Previous Permit Number and Date IssuedBefore Expvtiog Permit Transfer to Newnr <br /> e of POWTS stem/C /DCheck all that a 1n-Pressurized In-G on ❑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➢suite(explain) <br /> V.Dia ersaVl'reatm t Area Information: <br /> Design Flow(gpd) eslgn Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 349 O I . -7 41/011? <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u e <br /> ew TanksExisting Tanks v <br /> 3v ti <br /> Septieor Holding Tsolc w a <br /> 80rJ se <br /> Dosing Chamber <br /> VII.Responsibility St tement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature // MPh <br /> P/MPRS Number Business one Number <br /> 12111--le- l%0 /Lin J 1 /7 dpfS�S/ -7 <br /> Plumber's Plumber's Address(Sir-m-1,City,State,Zip Code) <br /> �-27(ao H � 3.S- Gt/ebss r.� L✓t 59693 <br /> V I1.n[I <br /> ent Use Ont <br /> Approved Pe.-rtymit Fee Date Issued Issuing gem Signature <br /> Given Reason for Denial $`'��cc) <br /> IX.Conditions of Ap maUReasons for Disapproval <br /> LEC1YREIEDAttachto <br /> SBD-6398(R.01/07)Mal id thru01/09 13URNFTT COUNTY <br /> ZONING <br />