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Comf erce.Wi.QOY Safety E nd Buildings Division County <br /> N 201 W.I Was gton Ave.,P.O.Box 7162 Bu?N 7T <br /> trit <br /> sconsin Madi n,WI 53707-7162 Sanitary Perm Number(to be filled in by Co.) <br /> epartment of Commerce 4'q S 41-31 <br /> State Transact on Number <br /> Sanitary Permit Ap lic tion <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission pf�his am to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Appination to— for state-owned POWTS are Project Ad s(if differen[Ihanmailing address) <br /> submitted to the Department of Commerce. Personal Information you rovide may be used for secondary <br /> purposes in accordance with the Priva Law s.15.04 1 suis. <br /> I. Application Information-Please Print All Inf rmation Parcel# <br /> Property Owner's Name <br /> Cab - -o3-baa <br /> /�Ta Property Loct tion <br /> Property Owner's Mailing Address <br /> Govt Lot <br /> r� 4 <br /> City,State Zip Code I Phone Number Ne 9, 0,1 7., Section -219r <br /> (circle one 7 (�\ <br /> la LrG'• /: 5�/dl �l��f"f' ��/° T� R1�Eo(Svv <br /> II.Type of Building(check all that apply) Lot# <br /> Subdivision I nine <br /> Irl or 2 Family Dwelling-Number of Bedrooms — <br /> I Block# Lof l sr77 v q p. /8, � <br /> D Public/Commercial-Describe Use D City of <br /> CSM Number ❑Villageo <br /> ❑State Owned-Describe Use PTown of e <br /> III.Type of Permit: (Check only one box on line A. Co lete me B if applicable) <br /> A' NeW System D Replacement System D Trea ent/l lolding Tank Replacement Only ❑Other Mo lification to Existing System(explain) <br /> B. D Permit Renewal D Permit Revision ❑Chou, Owner of lumber <br /> ❑Permit Transfer m New List Previo Permit Number and Date Issued <br /> Before Expiation Owner <br /> IV.T e of POWTS S stem/Com onent/Devic Cher all that apply) <br /> YNon-Pressurized In-Ground -D Pressurized In-Ground D.At-Gm e D Mound>:24 in.of suitable soil D Mound 24 in of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) ❑Pretreatment Device(explai ) <br /> V.Dis ersalfrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) ispe Area Required(at) Dispersal Area Proposed( System Elevation <br /> oU �2 Y•G ' <br /> VI.Tank Info ' Capacity in j oral #of Manufacturer <br /> Gallons Gallons Units m °d <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank pCj t <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume possibility for installation of the POW <br /> TS shown an the coached plans. <br /> Plumber's Name(Print) - Plutitber'a Si amre MP/MPRS Num er Business Phone Number <br /> rGGt o.riG o ;3kr-c _.7: i <br /> Plumber's Address(Street,City,State,Zip Code) j <br /> l `/L 14/ T• /LO- <br /> VI .Count /De artment Use Onl <br /> Permit ce Date Issued Issuing a ignatme <br /> Approved ❑ Disapproved $ I 7 1 <br /> D Owner Given Reason for Denial M <br /> IX.Conditions of Approval/Reasons for Disapproval I <br /> Attach to complete plane f r the syste and a buil to the Caunly only on paper no[lean then s IR x 11 in ha in size <br /> SBD-6398(R.01/07)Valid tbm 01/09 <br />