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meree.wl.gov Safety and Buildings Division County? <br /> 201 W.Washington Ave.,P.O.Box 7162 Uurn e'ff <br /> tio-zPCMadison,W1 53707-7162 Sanitary P✓ermit Number(to be filled in by Co Jrn of Commaroe J 0.35+- ` 1 <br /> Sanitary Permit Application <br /> State.Transaction �j J <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Q V �� <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 <br /> purposea in accordance with the PrivacyLaw,e.15. 1)(m),Stats. (o s0.f� e rj f F L 4 n e <br /> I. Application Wormation-Please Print All Information s,I <br /> Property Owner's Name �L�- Parcel 97'63Z-Z-41-1(4. -S/5-?%-OLJQRD <br /> van pelf;S —ft �, 031.910 S"0} leo <br /> . <br /> Property Owner's Mailing Address Property Location <br /> 3780.7 37('+A Ln Govt Lot <br /> City,State Zip Code Phone Number Yy Y., Section sl y <br /> Sr. �GiafY /�I✓ S(r081cncle ane) <br /> G T y/ N; R <br /> IL Type of Building(check all that apply) Lot# lf <br /> d 3 /I Subdivision Name <br /> Ly 1 or 2 Family Dwelling-Number of Bedrooms <br /> Block# l cQ <br /> ❑Pubhe/Comme tial-Describe Use ❑City of <br /> CSM Number El Village of <br /> ❑StateOwned-Describe Use <br /> Town of s'w/JS <br /> 11L Type of Permit: (Check only one bo:on tine A. Complete line B if applicable) <br /> A. a New System ❑Replacement System ❑ Tmatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com ent/Device: Check all that ap 1 <br /> d Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaUrnatment Area Wormation: <br /> Design Flow(gpd) Design Soil Applicatioi Rate(gpdsf) Dispersal Area Required(sf) D-penial Area Proposed(sf) System Elevation <br /> /. <br /> ' so '7 64,3 6p8' 93. 0 <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gathers Unita '$ _ <br /> New Turks ExistumgTmmks 3 §' It 9 <br /> Septic or Holding Terdr /6470 <br /> /000 S��r✓ X <br /> Dosing Chamber <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Aurone Number <br /> 866 <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> VI L CourtWe artment use onl <br /> 17;rm,—tf�- DawlsucdApproved ❑Disapproved Issuing ignature <br /> ❑ Owner Given Reason for Denial $'3 <br /> .Z5 1 S,t,�'2010 <br /> IX.Conditions of Approval/Reasora for Disapproval <br /> Attach to complete phm,far dere system ab submit tithe County only an paper not taw than 81n a 11 bathes in etre <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />