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Commeree.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 BCA 0-11Q'/'/' <br /> y(i sen n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Daparlm.r,r cf Cammarea .5322 <br /> 79 <br /> Sanitary Permit Application State T sneak 1u/mbero <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �w`7 t�✓�er�t� _.{-- <br /> unit is required prior to obtaining a sanitary permit Now: Application forms for state-owned POWTS we Project Address(if different tlum mailing address) C� <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 7•.J <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m,Stats. <br /> I. Application Information-Please Print All Information R 489 bR/./ser+ /7oP' <br /> Property Owner's Name Parcel#6 7 O 3rJ A N/ <br /> G4Arf•idSGM�Lf/C3�a� /� troaW PJN <br /> Yi 49- e/rQ90 0 2 025 o/Ico <br /> Property Owner's Mailing Address Property Location <br /> 0`1 Gwt Lot <br /> City,State Zip Code Phone Number <br /> Yy Y., section 3S" <br /> 13u F'fQ,!. M Ss3/.7 (circle one) <br /> IL Type of Building(check all that apply) Lot# 8e5 1/[y 4.1' 1 T /// N; R L1, E"19 <br /> JR l or 2 Family Dwelling-Number of Bedrooms H V,dFeAf-1& . 7 Subdivision Name <br /> Block# J' -�3 t s K y <br /> ❑PubfidCommaees <br /> ial-Dcribe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of Ser./i Jl <br /> III.Type of Permit: (Check only one box on Hue A. Complete line B if applicable) <br /> A. ❑New System ry <br /> y vi Replacemwt System ❑Treatment/HaWing Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision I r I `4 -�'5� <br /> Before ExpirationOwner V <br /> W.Type of POWTS stem/Com onentMevice: Check all that apply) <br /> on-Prequr¢ed In-Ground ❑Pressurized In-Ground ❑ At-Cmh ❑Mound>24 in.of su�sble soil ❑ Mond<24 in,ofauinble soil <br /> Holding Tack ❑Othar Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVrtreatiment Arm lnfia matim: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Disposal Area Required(at) Diaponsal Area Proposed <br /> (at) System Elevation <br /> G00 . 7 e 7 'Y-U . Aei"Cr. 9If 1{0 <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallon Gallons Units yq o v <br /> New Tanks Existing Tanks Q00 U �b a <br /> Septic or Holding Tank <br /> Dosing Clamber <br /> VII.Responsibility Statement-1,the undersigned,amsume responsibility for installation ofthe POWTS shown on the attached pians. <br /> Plumber's Name(Print) Plumba's Signahne MP/MPRS Number Business Phone Numbs <br /> RI c/c 1 /2,-, G. 8 57 7/S X;& -`//57 <br /> Plumber's Address(Street,City,state,zip Code) <br /> ,47760 /car 3S We6sfsar f.✓r' X843 <br /> VIILCoum only <br /> n /De arsent Use <br /> Approved ❑Disapproved Permit Fee I Date Issued I Issahtg Ag lure <br /> ❑Owna Given Recon for Denial 1395'v <br /> IX.Conditions of Approval/Reasenv for Disapproval <br /> Amarh to eanq kla pans for the syaew,and onhsit tathe County only an paper oat has than 8 to 111 haha M afu <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />