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commerce.wi.gov Safety and Buildings Division County II�� _ <br /> 201 W.Washington Ave.,P.O.Box 7162 Jou v p e-04- <br /> tisconsin Madison.Wl 53707-7162 SanitaryPe nil Number(mbefilledinby Co.) <br /> Department of Commerce Cz/ / T./ 8 <br /> Sanitary Permit Application Slate Transaction Number <br /> In accordance with a.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 are Project Address(if differenl than mailingaddress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> EEposcs in accordance with the Privaa Law,a.15.04(1)(m),Star, 3 O 7/S /3rp/fs/iQW /�O/ <br /> 1. Application Information-Please Print All information <br /> Property Owner's Name Parcel q <br /> /3ab Col 6P, 03� - S�l `j o3Jor] <br /> Property Owner's Mailing Address Property Location <br /> /H lot Nr 11vtrw Ave <br /> City,Slate Zip Code Phone Number Govt.Lot <br /> X, Y., Section /9 <br /> EG n r7?/t/ .S-SJOI l (nS/ HS-M /dS� (circle <br /> T e// N; R /,cne <br /> IL Type of Building(check a6 that apply) Lot# <br /> 0 l or 2 Family Dwelling--Number of Bedrooms '3 I Subdivision Name <br /> Block 8 <br /> ❑Public/Comm acial-Describe Use <br /> El city of <br /> ❑State Owned-Describe Use CSM Numbern El Village of _ <br /> Vr 3 Y, � ly� /q ®Town of <br /> tiSwrJJ <br /> 111.Type of Permit: (Check only one boa on line A. Complete line B if applicable) l <br /> A. ❑New System y 19 Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change o£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 /> Q Non-Pressurized In-Ground ❑ Pressurized I,Ground ❑ At-Grade ❑ Mo..d>24 in..fsuitable soil ❑ Mound<24 in.ofsuitnble soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dls ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(af) System Elevation <br /> l/S'o . 7 Gua (oyJ 9a. 00 <br /> VI.Tank Wo Capacity in Total N of Manufacturer <br /> Gallons Gallom Units v <br /> New Tanks Existing Tanks o V '� <br /> Septics Holding Tank /000 <br /> /eoo / Lm. Goticr> ><p <br /> Dosng Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) / Plumber's <br /> �Signature <br /> � MP/MPRS Number Business Phone Number <br /> /�Je % f7p /Gn-5 Jam- airy iJ�L -SSI7/J= S66-7080 <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> ,27760 / w <br /> ,V 111.Corm /De artment Use Ont <br /> IG Approved ❑ Disapproved Pemmt Fere❑ Owner Given Reason for Denial S Sop � "DawlssuedlssuingA <br /> IX.Conditions of ApprovaluReasons for Disapproval <br /> Attach to roaplelr plans for the system and submit m the County only on paper rot tem than 8 in a 11 inches in alae <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />