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commerceml.gov Safety and Buildings Division County <br /> Ahlb 201 W.Washington Ave.,P.O.Box 7162 13� v A <br /> i sco n s i n Madison,WI 53707-7162 Sanitary <br /> Permit Nu/member(to be filled in by Co.) <br /> Departrrreta of Comtnerms T$ t(21 tp <br /> Sanitary Permit Application State <br /> Trans.fi nNumber <br /> In accordance with s.Comm.8321(2),Wis.Adm Code,submission of this form m m <br /> the appropriate govanental /433-526 <br /> unit is required prior to obtaining a sanitary permit Note: Application forma fa statcowncd POWTS me project Address(if ditferent than madingaddros) <br /> submitted to the Department of Commerce. Persoml information you provide may be used for secondary <br /> em in accordance with the Priv Law,a.15. 1 m,Sha. A l <br /> I. A Bcation Wortnation—Please Print AB Information Na alert 4A,/U <br /> Property Owner's Name parcel# <br /> DAVL �0✓!7L o»I 'e'^ �a5 Oil. O 'f 3o.S-o 3 - 1 <br /> Property Owner's Mailing Addrms Property Location <br /> So x 3'k-c- Govt.Lot <br /> City,State Zip Code Phone Number $ <br /> A a1r ,3w Yy section S— <br /> W-P-hjfr✓ W:p- •rt/'f53Gt6 - 4o8U yo (circle me) <br /> IL Type of Building(check all that apply) Lot# T N; R E or& <br /> 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ®Public/Commercial—Describe Use LA—/q ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of a/ <br /> Town of a/r/1/AIC1 <br /> III.Type of Permit: (Check only one box on Hue A. Complete tine B if applicable) <br /> A. New System ❑ <br /> s� Y Replacement System ❑Treatmmt/Holding Tank Replacemml Only ❑Other Modification to Existing System(explain) <br /> B. ❑permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pmoit Transfer m New List previous Permit Number and Date Issued <br /> Before Exprtatiott Owner <br /> IV.Type of POWTS tem/Com ent/Device: Check all that apply) <br /> 1WNon-Pma&mucd InGmund ❑Pressufvsd In-Ground []At-Grade 11Mound>24inofsuitablesoil ❑ Mound<24 in,of suitable soil <br /> ❑Holding Tack ❑otherDapensl Component(explain) ❑Pretreatment Device(explma) <br /> V.DispersaV17matinent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Disposal Asa Proposed(If) System Elevation <br /> /*'o 7 at�7 I 1.f8 <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ,,g <br /> New Turks Existing Tata y7 y §' a <br /> cC y 3 v, 'w c7 a <br /> Septic or Holding Tank <br /> Doamg Chamber <br /> VII.Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans <br /> Plumber's Name(Print) Plumber's Signaturra MP/MPRS Number Business phone Number <br /> Rick !�� 4" J I /2-e-Aaa.eY 141& ci�s-Ssi lis=a�oG- v�r > <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> ')7 76 0 X/, 3.4- w-e.d s�r itis s(t S y 3 <br /> VIIL Cam /De armrest Use Only <br /> Approved ❑Disapproved Pomrt Fee Dam Issued Iasamg <br /> 8 '?'5c) D <br /> 11owner Given Reaeoafa Daniel <br /> IX.Conditions of Apprwal/Reaaons far Disapproval <br /> Atlaeh m os�pMe pointer lite syatea and subea m the C^aaay ady m paper tet Iew than a to x 11 Inches has[. <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />