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OomnerCe.wl.goV Safety and Buildings Division County <br /> 201 W.Washington Ave,P.O.Bax 7162 pkv Qtt <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Pani Number(to he filled in by Co.) <br /> D"m t., ra of Com me ;4-?a40 7 <br /> ter <br /> Sanitary Permit Application Stere Transac' n—- <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 stateowmd POWTS we Project Ad (if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be need for secondary / ,7 <br /> purposes in accordance with the Privacy Law,s.15. 1 m,Stats. <br /> 1. ApfiRcistion Information—Please Print All Information <br /> Property Owner's Name Parcel q <br /> /Za ZoOS f 3a Q 036 - 1707.;' -QO tY 600 <br /> Property(Tuna's Mailing Address Property Luciano 111�-1 <br /> /,fatd ,Jo w ej 19t/a Govt Lot <br /> City,state <br /> Zip Code Phone Number Y., Yy Section 3 6 <br /> sr fQa ( /fr/✓ S"-S�/aS� (qr//- 6f'O- 3879 (cncto— <br /> IL Type of Building(check aU that apply) ) Lot g T �/O R /"7 E or(�i <br /> 19 1 or 2 Family Dwelling—Number of Bedrooms Subdivision N e <br /> Block# 1 ei <br /> ❑Public/Commercial—Dermbe Use ❑City of <br /> ❑State Owned—Deaeribe Use CSM Number ❑Village of <br /> ®Town of 40/0y <br /> IIL Type of Permit: (Check only one box on Hue A. Complete tine B if applicable) <br /> A' ❑New Synea B Replacement System ❑Trestment/Holdiog Tank Replacement Only ❑Other Modi ication to Existing Syn®(explain) <br /> B. ❑Permit Reaewal ❑Permit Revision ❑Change of Plumba ❑PermitTransferto New List Previous I mmut Number and Date issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com ent/Device: Check sU that apply) <br /> ®Non-Preumixed In-Gromd ❑Pressurized In-Ground ❑At-Grade ❑Momd>2A in.of suitablesoil ❑Mound< in.efsuitable soil <br /> ❑holding Talc ❑0trerDopmal Component(explain) ❑Pceheatment Device(explain) <br /> V.Its ersaYrreatment Area Informadm: <br /> Design Flow(gpd) Design Soil Application Rate(gpdaf) Dispersal Area Required(Of) Dispersal Ares Proposed(sf) System Elevation <br /> 300 1 . 7 yes -7 Z/a,4 9v o <br /> VI.Tank Info CsWcitYin TOW kOf Manufacturer yy <br /> Gallons Gallon Units U'S O <br /> New Tends to isum Isms y F3 y 3 <br /> yS ]I tza F. <br /> Septic or Bolding rank S'O O X <br /> D..%Chamber <br /> VII.Responsibility Statement-I,the undmigned,assume rnponsibility for installation of the POWTS shown an the an hod plana <br /> Plumber's Name(Prod) Plumber's Signature MP/MFRS Nando Business Phone Number <br /> AF,c/C /SAO k/ <br /> Phmber's Address(Stree�t,City,State,Zip Code) <br /> / <br /> VIIL Cam /De artment Use Only <br /> rApproved 1 ❑Disapproved Pamiff m Date(;sued —t Issuing Signature <br /> ❑Owner GivenReasonfor Denial S WS 1 )k A Q/ <br /> IX.Conditions of Appraval/Reasom for Disapproval <br /> Aaadhbeompkte plansfortherysrem and ahbsatatbr County only on papermtles thaa9Lr xll iscim Metra <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />