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commerce.Wl.gov Safety and Buildings Division Counry, <br /> 201 W.Washington Ave.,P.O.Box 7162 B ao-` ,j Q. - <br /> iseo ns i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Oeparlment of Commerce 632 10 <br /> 2' <br /> Sanitary Permit Application State Transaction QNuumber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �j0-1 r ISUI&J <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different t nmailingaddress) <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 I m,Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> eS Q <br /> 0-en A-re_ <br /> Property Owner's Mailing Address Property Location <br /> a6 / Govt.Lot <br /> City,State Zip Code Phone Number A <br /> N'W Y., .SGJ y,, Section l <br /> cuc <br /> H�• J/8'Gf� r763 �l�l q le one].,, <br /> c t T3 / N; R�Eorw <br /> H.Type of Building(cher ll that apply) Lot# <br /> 1E or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> l Block# <br /> ❑Public/Commercial-Describe Use �— �` <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Ill.Type of Permit: (Check only one box online A. Complete line B if applicable) _0 _ <br /> A. $-New System ❑ Replacement System y p y ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Perri[Transfer m New <br /> Before Expiration Owner <br /> IV.T e of POWTS System/Component/Device: Check all that apply) <br /> on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersat/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> �v -7 ya s� 9s-o <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks - U <br /> 0 <br /> a` U io <br /> Septic or Holding Tank �� `D An C_ <br /> Dosing Chamber J <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) /� Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,Q6A---S/ Si;P � GtJ� �f 72 <br /> VIII County/Department Use Only <br /> ff'Approved ❑Disapproved Permit FeeDateDate Issued Issuing Age ore <br /> ❑Owner Given Reason for Denial $ 3.25P' ��8) <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 6 U]a 11 Inches In size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />