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commerce.wl.gov Safety and Buildings Division County ../- <br /> 201 W.Washington Ave.,P.O.Box 7162 Q N r A) e-1 <br /> tasepartmeordsconsin Madison,WI 53707-7162 Sanitary Peermit Numbeer(to be filled in by Co.) <br /> of commerce sJ z'2J0 1,1 <br /> State Transaction Number <br /> Sanitary Permit Application �evlew <br /> In accordance with s.Comm.93 21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental O <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 /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name f Parcel# 0/4, '.34/S� o310D( P <br /> J a 7 0/� �? S 90 C' <br /> Property Owner's Mailing Address / Property Location <br /> / Csj Gf Govt.Lot <br /> City,State Zip Code Phone Number �) y,, =y,, Section /:5 <br /> :7 1,one <br /> .—OLac�C� T RL:E� <br /> IL Type of adding(check all that apply) Lot# <br /> '�.I or 2 Family Dwelling-Number of Bedrooms�A Subdivision erne <br /> Block# <br /> 0 Public/Commercial-Describe Use - e <br /> ❑ City of � <br /> �..-' CSM Number El Village of, r <br /> El Owned-Describe Use <br /> _�- OTown of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 44-New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> List Previous,Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.T e of POWTS S stem/---------UDevice: Check all that apply) <br /> XNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dis ersairrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) 7M-ufact-el <br /> (sfp System Elevation <br /> 3 �, .z 9 5 UbVI.Tank Info Capacity in Total #of Gallons Gallons Units 'dym `c « .. v �'New Tanks E%ISIIna Tankso 2w` V yr H y 'wOSeptic or Hakes,-Tk _ !�'�i <br /> Dosing Chamber V <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) PlumsSig�� MP/MPRS Numb�r Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Conn /De artment Use 0 <br /> Perini[Fee Date Issued Issuing a ignamre ' <br /> Approved 0 Disapproved S <br /> 0 Owner Given Reason for Denial 325 f _36j. / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 811E a 11 Inches in site <br /> SBD-6398(R.02/09)Valid thin 02/11 <br />