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commeree.wi.gov Safety and Buildings Division Coun <br /> 201 W. Washington Ave.,P.O.Box 7162 4 _ , <br /> 'WisconsinPaccordance <br /> Madison, W1 53707-7162 Sanitary Permit Number(to be filled in by Co I <br /> artmem of Commerce i I Q/ C <br /> Sanitary Permit Application Slate Iransa tion Number <br /> s'.Comm.83.21(2),Wis. Adm.Code,submission of this form to the appropriate governmental -'Cl- <br /> rior to obtaining a sanitary permit. Note, Application forms for state-owned POWTS are Project Address(if diffFrent than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary a/1/�/ <br /> purposesith in accordance wthe PrivacyLaw,s. 15.14(1 xm),Slats. `-� <br /> 1. Application Information-Please Print All information 0 <br /> Propern Owner's Name Parcel N <br /> ItCQ ] <br /> Q' �M4P . (&4 / - pp- Z 00 400 <br /> Properrm'Owner's Mailing Addre s Property Loc tion <br /> I�L y 9 C/3 o Id 3S Govt.Lot <br /> Cin,State Zip C'o`ddeep Phone Numbers/o q �� 4 y, S y,, Section <br /> UIh++�- t � tr SY"07� �� � YI ' � / �'3 -/'r`-�''q�� coc]eon <br /> Il.Type of Building(check all that apply) Lot a .f�7-I-- R�F oteW <br /> N1I or 2 Family Dwelling-Number of Bedrooms7 � � Subdivision nnc <br /> Block# 444 Ind 4,-t <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of _ <br /> ❑State Owned-Describe Use CSM Number ❑ Village of _ <br /> Q(Town of N a", <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New S stem <br /> Sy 11 Replacement System ❑Treatment/Holding'lank Replacement Only El Other Mod lication in Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Pennit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<:4 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) _ <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Flevatio� <br /> 300 i ySV_ 91.0 ' <br /> VI.Tank Info Capacity in Total k of Manufacturer <br /> Gallons Gallons Units o v <br /> New TartsExisting Tands <br /> °1 0 <br /> a` V h y rn iL U n. <br /> Septic rHolding'laid, <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the on sumo responsibility for instaflation of the POWTS shown on the allehed plans. <br /> Plumber's Name(Print) Plum is Sig tore MP/MPRS Number Business Phone Number <br /> �S 6Pr l SL ��' �- <br /> Plumber's Address(Street,Ciry,State,Zip Code) <br /> 7 -V 6 1� 3 <br /> VIII.Count /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee gDate <br /> �ued '7 Issuing I Signature <br /> ❑ Owner Given Reason for Denial E f�15 b/ r <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 8 Ili x_Hmeh"hisme <br />