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commerceml.gov Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 Cff 71 Q <br /> j,f i scon s i n Madison, W1 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Depertmem of Commerce � / A <br /> Sanitary Permit Application Slate Transaction Number <br /> In accordance with s.Comm. 83.2](2).W is. Adm.Code,submission of this form to the appropriate governmental /46 <br /> unit is required prior to obtaining a sanitary permit Note: 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 l�/`-') <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1 xmf Stats. ✓.-r, <br /> 1. Application Information-Please Print All Information / 1/�•l. <br /> Proper}Oymer's Name Parcel q <br /> H, 61rfi 4-11 E d(�c� �3a o/ -� -o.�- s�� <br /> PropeemT Owner's Mailing Address Property Location <br /> / 6� (/-e— Govt. Lot 1 <br /> Crv.State {Zip Code Phone Number Section <br /> OSCeo V lis c;W`/-3a7S1 circle on <br /> Il.Type of Building(check all that apply) Lot a T N, R 1.r r w <br /> �I or 2 Family Dwelling-Number of Bedrooms /-- Subdivision Name <br /> Block q <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑Slate Owned--Describe Use CSM Number [•0 7 11Village of <br /> o'3 {-LOYZ , Jt fawn of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑ "frea[menUl folding Tank Replacement Only [I Other Modification to Existing System(explain) <br /> B. ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal El Revision g ❑Permit Transfer[o New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade KMound>24 inof suitable soil `❑ Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Desi n to, (Jg7pd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area 5_0 <br /> (s0 System FQlevalion <br /> J V l _0 / �`.' o <br /> VI.Tank Info Capacity in I otal M of Manufacturer <br /> Gallons Gallons Units" u <br /> New Tanks Existing Tanks c u 2 <br /> t] rL <br /> gOlot <br /> ding Tanber <br /> X cob <br /> VII. Responsibility Statement- 1,the undersigne ,assume responsibility for installation of the POWTs shown on the attached plans. <br /> Plumber's Name Print) Plu ber's Signatu' MP/MPRS Number Business Phone Number <br /> Al,(S 71V <br /> Plumber's Address(Streetate Wiry,StLip Code <br /> 70pv5' 6 �,... �d <br /> VIII.County/Department Use Only <br /> Permit fee Date Issued Issuing gem Signature <br /> Approved ❑ Disapproved //�� Pn� /)_ ��7 �-t�/�� ,.� <br />• ❑ Owner Given Reason for Denial S Soo•VV /V -4th-o I l I ai 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ntaeh to complete plans for the system and submit to the County only on paper not less than 8 u:x I I inches in size <br />