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COltlfil8l'C@.WLgOy Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 i6-e/-A)E <br /> bl- <br /> sconsin Madison,W153707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce s'�'O31p Z <br /> Slate Transaction Number <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary SSM <br /> purposes in accordance with the Privacy Law,s. 15.04 I m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's <br /> ner's�NJee a Parcel 61 _3 <br /> L <br /> _. <br /> C/i4/t1 zj E D4r,,c(wa k4A& a S o� 4261--- --- <br /> Property Owner's Mailing Address Property Location <br /> as 77 /� ' _ - - Govt Lot y_, $[11rw 3� <br /> City,Start Zip Code Phone Number y, ,tJ VO /, Section 3J� <br /> �/pL` p 2 ?p� j,(circle one <br /> G_�Ait) S�bf/ 107 e,4 t? / N; R /X .800 <br /> II.Type of Building(ch ell that apply) _ - Lot# C�C7 <br /> 3 — --- <br /> ,ubdivision Nanic <br /> Phor 2 Family Dwelling-Number of Bedrooms _-_— <br /> _— <br /> Block# �- <br /> ❑Public/Commercial--Dcscribc Use_ [I city o(_,_ <br /> �— CSM Number <br /> Ll <br /> of <br /> ❑State Owncd-Describe Use __.._.- --_. _. __ .____- c� ,�G- �(lvd _K/�JQ./� <br /> Town ol'___ <br /> DI.Type of Permit: (Check only one box on It..A. Complete line B if applicable) <br /> A' ❑New System `Replacement System ❑TrcannenUi folding Tank Replacement Only [I Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑ PerRenewal El Revision ❑ Change of Plumber El Permit Transfer to New <br /> Peoria <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Componeut/Device �Chec all that-�QIyZ___ <br /> on-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 m of suitable soil ❑ Mound<24 in of suitahlc soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)-- <br /> V. <br /> explain)-V.Dis ersal/Treatment Area Information: -- - <br /> Design Flow(gpd) Design Soil Application Ratc(gpdst) Dispersal Arca Required(sf) Dispersal Arca Proposed(sl) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer ?: <br /> Gallons Gallons Units p v U y p <br /> New Tanks Esion,Tanks N c e m m <br /> a V .vi ts on w V d <br /> Septic nr rmmng,.Nk <br /> JF <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW I'S shown on the attached plans. _ <br /> __—-- <br /> Plumber's Name(Print) Plumber's Signanire MP/MPRS Number Business Phane Number <br /> - -,z.7d 9/ yl�j 7x 8 6 <br /> Plumber's Address(Street,City,Stgte,Zip Cade) <br /> ,QoF� <<f S �re.� w� SY87� -- -- — — - <br /> VIII.Count ID�artment Use Only - -- - —�-- ---- -__- - <br /> ' -- Pemul Pec Date Issued Isswng [Signature <br /> W( Approved ❑ Disapproved S ¢ <br /> ❑ Owner Given Reason for Denial sJ J�A �J` — - - —-'- - <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Altaah to camplele plain for the ryslem and sub.1.1-51,e C-only ualy on paper nut less(hen tl IIE t 11 Inches in size <br /> SBD-6399(R.01/07)Valid thru 01/09 <br />