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commerce.wi.gov �� Safety and Buildings Division County 7 <br /> 201 V'_ Wa hingon Ave_, P.O. Box 7162 7, l f r ----- <br /> iSeonSiMadison, wi 5 3 7 67-7 1 62 Sanitary Permit No mber(lo be t- -in by—Co <br /> .) <br /> Department of Commerc� � <br /> Sanitary Permit Application ClCren,aC=tion Number U <br /> In acco¢Lanee s.ith s Comm. 83.21(2)"Wis. Adm_Code.submission of th is form to the appropriate governmental '„J,) �s�2- ((( J <br /> f <br /> "Loh, <br /> mi- <br /> required pour to Obtaining a senitan perms. Note' Application forms for slate-owned POWTS are Project Address(if different than mailing address) <br /> "ohmiltzd m the Department of (oinmerez Personal information VOL] provide may be used for s,cond,, (� <br /> purpmc,m accorda rice w o Ih c I rivac Lav,..s 15.04(I)(m),Stals. �1 <br /> l , lication Information-Please Print All Information r — mom <br /> I'ropert.(�srner s me — - <br /> Pa el N <br /> fDes61- ' oo <br /> P perp Orsnie Mmhne Address <br /> (fle dez r- 40/`J Propem- Location <br /> Cin_Statz VGovl. Lot_ <br /> Lip Code Phone Number <br /> r Q N, (.� r ,[ / _._ 'N, Section �C) <br /> �— �� f t q r �'rcle on6 <br /> 11. Type of Building(check a I that apply) Lot p T __I N: R yl ]3•=--g.6 lV <br /> 1 ort Famih Dwelling-Number of BedroomsSubdivision Name <br /> Block4 6, ov <br /> i �Pubhc/Cornmcrciel-Desmbc Usc <br /> ❑ Cily of <br /> �. Stale Owned-Ucsrnbc Use_ CSM Number ❑ Villa <br /> ge of <br /> I vpe of Perm iC (Check only one box on lineA. Com tete line B if applicable) <br /> New A,stem D Replacemem System T <br /> ug-Tank Replacement Only ❑ Other Modification to"'""ung tiystem(explain) <br /> l f e ma Renewal D Permit Revision - -- <br /> B List Pre Perms Number and Dale Issued <br /> Change of ❑permit To mvfer to New <br /> Befog ICepimlion caner <br /> IL'.Type of POW"fS Stem/Com pLl <br /> onent/Dev'ee: (Check all that apply) ��� <br /> Non-Prelsurtzed m-(imund D Pressurized In-Ground D APGradc I(Mound 24 in.ofsuit a ble soil ❑ Mound<24 in.of sui le soil <br /> �] Ilold mg lank ❑Other Dispzrsal('omponem(explain) <br /> ❑Pretreatment Device tspersal/"I'r (explain)_ <br /> eat <br /> men[Area Information: --- <br /> i Design No, (gpd) �esign Soil Application Rat - _ <br /> e(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(0) system Elevation <br /> Tank Info Capacity in Total N of -- - <br /> Manufacturer <br /> Gallons Gallons' Units <br /> NewTanks Es"on, d U m <br /> 6 tanks B <br /> s, <br /> L <br /> 44 <br /> tank �• J V' w VI 4- �% C <br /> � <br /> J <br /> in <br /> - - cal�S' <br /> 11. Responsibility Statement- I,the undersign+—!L�ud <br /> e respolationoCthePOWCSshnonthe attached plans.Plnature __ <br /> MP/MPRS Number mess Phone Number <br /> _ ___ y 2z Szz �7ts <br /> Ilumher s Address(Snect.Cih sta Zip <br /> i7 <br /> bili. County/Department Use Onl <br /> _ <br /> l pprove.d <br /> VD Disapproved Perms ero I'e, Dad�te Issued Isswn AGem signature <br /> ❑ Owner Given Reason Nr Denial g� ' �� �Ll`���UU � �- r <br /> IX.Conditions of Approval/Reasons for Disapproval l <br /> PO4 Tank RePL<,-Acx)T 1�115 Tg1UK COLCAIP5E0. <br /> 1 <br /> \nach to cnm plele plans for the system and submit b the Count,-only on peper not I¢than a is x I inches in soe <br />