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commerceml.gov Safety and Buildings Division County <br /> 201 <br /> iseo n s i n Madison,WI 53707-7162 Sanitary PerW.Washington Ave.,P.O.Box 7162 QkwN'eo <br /> mit Number(to be Filled in by Co.) <br /> I')eparnnent of Commerce I ✓ <br /> a C <br /> Sanitary Permit Application State TnnaactioOnNumber <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental —vi <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)m),Stats. �-// <br /> L A limtion Information—Please Print AB Information / <br /> Property Owner's Name Parcel# <br /> f3eb l/'Ofser) S C/.1 - 96S0 - ///0b <br /> Property Owner's Mailing Address Property Location <br /> 3/OD G(e.t oa/Cs /1vr /9 tern Gc� Lot <br /> City,State Zip Code Phone Number Yy Section it <br /> (tlhiftRes. UG WiN SS//O GSI- 774- 76Y1 (Circle-0 <br /> IL Type of Building(check art that apply) I.o T�_N; R /S E o( ' <br /> 9 1 or 2 Family Dwelling—Number of Bedrooms 9 yid Subdivision Name <br /> Faun Wi-60A <br /> ❑PublirlCommereial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> Town of )A G/C,91✓1 <br /> IIL Type of Permit: (Check only one box oa line A. Complete line B if applicable) <br /> A .�New System ❑ <br /> ys Replacement System ❑ Treatment/Holding 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 Expiation Owner <br /> IV.Tyipe of POWTS stem/Com ent/Device: Check all[lust apply) <br /> . Non-Preumized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Monand 24 in.of suitable soil ❑Mound<24 in,of suitable soil <br /> ❑Hotding Talc ❑Other Dispersal Component(explain) ❑Prcbeabnent Device(explain) <br /> V.Dis ersaVrreatment Arm Informatioes: <br /> Design Flow(gpd) Design Soil Application Rate(gpdef) Dispersal Area Required(af) Dispersal Area Proposed(sf) System Elevation <br /> q-4-0 S— q o D 90 to get • o /• o <br /> VL Tarek Wo Capacity,in Total #of Manufacturer <br /> Gallons Gallons Units $ o <br /> New Tanks &-fig Tanks c� s It m <br /> y m v, iw C S <br /> Septic er Holding Tank /BOO <br /> X <br /> 17osirg Chamber <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown os the attached plans. <br /> Plumber's Name(Print) Phanber's Signature MPIMPRS Number Business Phone Number <br /> �r cls NB k;r .S 2 4h-..0 CJs 8s-1 fir,6- vis 7 <br /> Plu nber's Address(StrcK City,State,Zip Code) <br /> 776 W Y 35- k-'ePI-I W7- -Sy 097 <br /> VI Court"/De Vse Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing A ignature <br /> ❑Owner Given Reason for Denial s 525 ° d54a" o9 <br /> DL Conditions of Apprwal/Reaaons for Disapproval <br /> Nou, -<oil abswgion Cells 4&" --co fx.^ LaialalY c." tali 9z es evell is I seg"( 70itiC <br /> Attach to cosplek plansfor ere rysou and subma tothe Coumy only on paper mt len than Sin a 11 Inches in sire <br /> SBD-6398(R.01(07)Valid thm 01/09 <br />