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coni 11erCe.Wl.gov Safety and Buildings Division Count <br /> 201 W.Washington Ave.,P.O.Box 7162 N r Q. <br /> isc o n s in Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Deparbnerd of Commerce J Z Z 51 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �, left) <br /> unit is required prior to obtaining a sanitary permit Note: Application fors 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 second ® �� <br /> purposes in accordance with the PrivacyLaw,s. 15.04 I m,Stats. <br /> L Application Information—Please Print All Information <br /> Property Owner's Name // Parcel# <br /> OG L// nn (�OII) Cs�lf�etn �IIs�ryOGhs_IrwtereikrJ.! .2 2 0 ooa <br /> Property Owner's Mailing Address 1 ,�/J( .Z�ilJ� "Vit. ()61� OMA Property Location <br /> t0 ` r't'b / /L S GR7DAra'/ )AA) alZ`9Govt.Lot 1 f� <br /> City,State Zip Code Phone Number <br /> Y., Section /;? Sq <br /> S�3o� T N; R / m Eone, <br /> I.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> _ Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑l Village of �-r- <br /> V_-5- 9) � / 1" '"wn of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. XNew System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only El 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 onent(Device: Check all that apply) <br /> P' 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> 3t �/Oc C/ so <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a v o 9 v <br /> New Tanks Existing Tanks v o U E '� <br /> Septic or Heldivg.Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,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 Phone Number <br /> i�Vi � e PN l zZ �6 9 - 7� a�6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> O k �le7l / e <br /> VIII.Coun /De artment Use Only <br /> Approved El Disapproved Permit Fee Date Issued Issuing n gnanue <br /> $ 7 <br /> El Owner Given Reason for Denial at.5 �G 10 JQh <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 in x I I inch.in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />