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Cownerce.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 "sen �e7`�- <br /> iseo n s i n Madison,Wl 53707-7162 Sanitary Permit Number(m be filled in by Co) <br /> oopartmant of commerce z4 D(o&4✓? <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.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 Now: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1 m),States. t <br /> L Application Information-Please Print All Information /s 9v -✓aribder 4,,,- <br /> Property Owner's Name Parcel# <br /> T�faMf.is f/ari`et^ >V- vols_ oar�o <br /> Property Owner's Mailing Address Property Location <br /> 3om0 W. �3Sra Sr. Govt Lot <br /> City,State Zip Code Phone Number <br /> ��jj v., section 3r <br /> VLA v n.S v I Arsera 3 7 circle oney., <br /> IL Type of Building(check all that apply) .ar.aLot# T V N; R le ( E 0(1IV <br /> ®t or 2 Family Dwelling-Number of Bedrooms M1 ) 0 Subdivision Name <br /> Block# <br /> ❑PubEcJCommerraal-Describe Use ❑city of-) <br /> ❑Stare Owned-Describe Use CSM Number ❑Village of <br /> 3 Town of SW 1 rr <br /> IIL Type of Permit: (Check only one box m tine A. Complete tine B if applicable) <br /> A. ❑New System ❑Replacement System y <br /> Treaonent/HoWing Tank Replacement Only ❑Otho Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New It Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS stem/Com eat/Devics: Check all that apply) <br /> ❑Non-Preasurized In—C and ❑Pressurized In-Gromd ❑M-Grade ❑Mound>24 in.of suitable aril ❑Morand<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispmsal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis erssUTreahnett Area hdormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arm Required(at) Dispersal Ara Proposed(at) System Elevation <br /> 3e 7 — — — <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units $ <br /> New Tanks Existing Tanis <br /> 3 R m <br /> V yr res ii 0 r� <br /> Septic m Holding Tank <br /> Dosing Clamber <br /> VII.Reaponsibitity Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) Plumber's Signature MP/IvfPRS Namber Baineea Phone Number <br /> R.,e-le- f{o k.ns 1 1' ,4� <br /> Plumber's Address(SticetlCity,State,Zip Code) <br /> VIIL Cam /De artment Use Only <br /> Approved ❑Diesppmved Permit FF= Data Issued Issum Signature <br /> ❑Owner Given Reason for Denial $ olv--t/ /0 <br /> IX.Conditions of Apprwal/Reasona for Disapproval <br /> Math to o npleh plan,for the system and submit to the County only on paper no tem than a in ail inches in she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />