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commeree.Wl.gov Safety and Buildings Division County <br /> seo ns i n Madison,Wl 53 707-7 1 62 San tary Permit N 201 W.Washington Ave.,P.O.Box 7162 L t, <br /> I <br /> u <br /> 5mber(to be filled in by Co.) <br /> Department of Commerce �b a 7 <br /> Sanitary Permit Application State Transaction Nu ber _ <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate govemmenlal �Q(JIC�J <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for stale-owned POWTS are Prolec[Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal infortnatimn you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 I m,Stats. <br /> 1. Application Information-Please Print All Information j -/'Y,<�. <br /> Property Owner's Name Parcel# C, /- C, 236 T;ii _ <br /> Rr i4r ed _ - n <br /> Property Owner'ys Mailing AddresQs Property Location <br /> Q/t}ss L�9-ke. C/ Govt.Lot 4 <br /> li City,Slate Zip Code Phone Number <br /> J /' Section Z 1 <br /> zJ <br /> A•N�a{r I�i-t _47 �7e�3U fl�' N; R�1-.Eonn <br /> 11.Type of Buil ng(check all that apply) T Lot# �� <br /> 9r 2 Family Dwelling-Number of Bedrooms '- Subdivision Name <br /> 1. .:. i Block# <br /> ❑Public/Commercial-Describe Use _� <br /> , ❑City of <br /> El State Owned-Describe Use CSM eN�um�beer ❑ Village of <br /> V/ / 11town of u/l1/ ON <br /> 111.Type of Permit: (Check only one box on line A. Complet=Replac-ementOnly <br /> le) _A. New System )(Replacement System D Treatmenement Only D Other Modification to Existing System(explain) <br /> B. D Permit Renewal D Permit Revision D Chan e oList Previous Permit Number and Dale Issued <br /> g Transfer to NewBefore Expiration <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> 7Alom-Pressurized In-Chound D Pressurized In-Ground DAI-Grade D Mound 124 in.ofsuitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain)_ D Pretreatment Device(explain) <br /> V.Disersal/Treatmen[Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(s0 Dispersal Area Proposed(st) System Elevation <br /> 5 O , 7 &4 O t stA io, 95-, 8 <br /> VLT'ank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u u v <br /> New Tunks Existing Tanks W — <br /> a` V ti N ii.co <br /> U a <br /> Septic or holding Tank 00 <br /> Dosing Chamber <br /> �. .,> 6S-0 165a <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumb4'r's Name(Print) /- Plumber's Signature MP/MFRS Number Business Phone Numbcr <br /> r� / "h r �� �..-�G yz7 4. c// ;� Y 9 -,2-2 � <br /> Plumber's Address(Street,City,Slate,Zip Code) <br /> /3�• � �y s/ J-e,J ts,� -3 Yk7­2 <br /> Vll I.County/Department Use Only <br /> Approved D Disapproved Permiittj Feeee' y� Dilate Issued 9� issuing A t ature <br /> ❑Owner Given Reason For Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �• ��d �LfGf6�E <br /> Attach to canrplete plans for the system and submit to fire Cuunpcud,nn paper not less than 8 UE x 11 inches in size <br /> SBD-6398(R.02/09)Valid IN u 02/11 <br />