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commerceml.gov Safety and Buildings Division county /—/j201 W.Washington Ave.,P.O.Box 7162 <br /> isconsin Madison,WI 53707-7162 Sanitary Permit Number 5(to be filled in by Co.) <br /> Dapartment of Commerce .551 1 !� <br /> Sanitary Permit Application State TansaCaionNumb{er ty <br /> In accordance with s.Comm.83.21(2),Wis.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-awned POWTS are Project Address(if different than retailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary �t <br /> purposes in accordance with the Privacy law,s.15. 1 m,Stats. r-7O <br /> I. Application Information-Please Print All Information l0 �7G / <br /> Prope�p wner's Name , / �C e Parcel# <br /> ,[S r r/'a e. /7 ' 07-042-2-38.13-4.2 64-060-01W <br /> Property Owner's Mailing Address Property Location <br /> F Z,$ 4cro <br /> of Gexrtat <br /> City,State L Zip Cto�dep[� Phone Number -y � S�s7-vy �y„ Section� <br /> GJ O ,o� 7 O J O � rclE one <br /> T N; R <br /> II.Type of Building c eck all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> XPublic/Commercial-Describe Use DCi of ^_ <br /> City _ <br /> 0 State Owned-Describe Use CSM Number ❑Village of pp II <br /> X-Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) - — <br /> A. El New Systemreplacement System ❑Treatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber 0 Permit Transfer to New List Previous Permit Numberand Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Comp onent(Device: Check all that apply) <br /> ❑Non-Pressurized In-Grotmd 0 Pressurized In-Ground 0 At-Grade KMound>24 in of suitable soil D Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design w(gpd) Design <br /> vel{ d Soil A licatloRte(gpsDa Required(siDispersala Proposed(s) System Elevation <br /> � <br /> . S <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a °' V' m <br /> New Tanks 77isting Tavksv <br /> d V <br /> Septic or Bdd' g T k 6 OO D I — a <br /> Dosing Chamber / <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility forinstallation of the POWTS shown on the attached plans. <br /> Plumber's Nam (Print) Plumber's Signature MP/1NPR5 Number Business Phone Number <br /> IPu S�7d�in lrJa� z-Z --�s'> ---� <br /> Plumber's Address(Street,City,State,Zip Code) r <br /> 14? b'k, i sir e -J w sy a <br /> VIII.County/Department Use On] <br /> DI Approved 0 Disapproved Permit Fee Date Issued Issuing A y5dwinamme <br /> D Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plane for the system and submit to the County only on paper not has than g in x I I inches in size <br /> SBD-6398(R.02/09)Valid duu 02/11 <br />