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OR 161 tv#t <br /> Gommerce.ayl_gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 b 4 <br /> Madison,W1 53707-7162 Sanitary PermitNumber(tohefilledinbyCo.) <br /> isconsin r ` t <br /> Depmbrlent of Conmasirce s3 z 2 8 q- W <br /> Sanitary Permit Application State Transaction Number <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-owned POWTS are Project Address(ifdifferent 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(l m,Stats. <br /> 1. Application Information-Please Print All Information i a d✓h �dM� <br /> Property Owner's Name � � Parcel# - / _ FD <br /> 002 <br /> Property Owner's Mailing Address Property Location <br /> LL) v _ +H Govt.Lot of <br /> City,State Zip Code Phone Number'/., /Va)'A, Section <br /> 1514 5 Q 44) , _ 6 - <br /> le <br /> one <br /> 11.Type of Building(check all that apply) Lot# T �N; R _E o <br /> �1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of }� <br /> Town of�// y <br /> Ill.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A, ;K New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ElPermit Revision 11Change of Plumber ElPermit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Tvrie of POWTS S stem/Com neot/Device: Check all that apply) <br /> , Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable snit <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 50 7 5 095J . 4 9:;o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v y <br /> New Tanks Existing Tanks <br /> eptic Hddimg Tank oOO i. It x <br /> Dosing Chamber U/ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) 1 Plum ignm me MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> O gg TR F v 1,yf, 5� <br /> VII .Coun /De rtment Use On <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing t <br /> ❑Owner Given Reason for Denial -3,7 5- Ala 2,00 <br /> IX.Conditions ol'ApprovaUReasons for Disapproval <br /> Attach to complete plana for the system and submit to the Countyonly as paper mot leu Man 8 t2 s l l inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />