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commeree.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 4 <br /> i s e o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application Sta,e TTrransaawnNumber <br /> In accordance with s.Comm.83:21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �Qr,.IeetJ <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—Privacy Law,s.t All I m,Stats. +t 733f S„L- LJ i 3� <br /> I. Application Informa6on—PleasePrintAlllnformation r>/ J .7TL F4 <br /> Property Owner's Name Parcel# <br /> oao --1/33 _oI900 <br /> Property Owner's Mailing Address Property Location <br /> vs- 4r/ He Govt.Lot <br /> City,State Zip Code Phone Number <br /> �'/.,.,��%., Section 3z <br /> SO K S Q � t/ )- (circle one <br /> l___N; RIciEo� <br /> II.Type of Building(check all that apply) Lot# nel__l___ <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> D Public/Commercial-Describe Use <br /> D City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> IXTownof <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) O -0 <br /> A, 0 New System A Replacement System 0 Treaunent(Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑permit Revision D Charige of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com nent/Device: Check all that apply) <br /> X Non-Pressurized In-Ground 0 Pressurized In-Oround D At-Grade D Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank D Other Dispersal Component(explain) 0 Pretreafitmt Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(god) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ca , 7 Y2 �So $G, 60 <br /> VI.Tank Info Capacity in Total I#of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> d g e rd A <br /> eptic r Holding Took _ <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned ssume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pin er's Signature MP/MPRS Number Business Phone Number <br /> Is oer 22t229 i b6460 <br /> Plumber's Address(Streett,,,City,State,Zip Code) <br /> a�CJ�/tt� C.` l� ✓V GxrOm� tom/f r J T <br /> VI .Count /De artment Use Only' <br /> Approved 0 Disapproved 1$ rm11 t Fee Date Issued issuing Age i re <br /> 11Owner Given Reason for Denial $ 32S-f ,rj 1 b9 <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 M x 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />