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CORM11erCe.Wl.gov Safety and Buildings Division Comely <br /> 201 W.Washington Ave.,P.O.Bax 7162 u r kf G <br /> 'Wisconsin of Madison,WI 53707-7162 SanitaryP a Number(m be filled irby Co.) <br /> 4e-)$mgggJ <br /> ' ?0 <br /> Sanitary Permit Application State Tran a4-Number <br /> Iv accordan=with s.Comm.83.21(2),Will Adm.Cody submission of dug form to the appropriate govemm mal 1 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms f«stdeowned POWTS me (\ 1 <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Prgcet Addrr{ss(if different tbss mailing address) <br /> em ie ac=rdance with the Priv Law,s.15. 1 m,Stats. <br /> L AppficationInformation-PlessePrintAIInformation 3070 <br /> Property Owner's Name IL Parcel# <br /> �r lee Cern waY (n)sw GwNctx d 3d -�/9 - o3/m O <br /> Property Owner's Mailnrg Addma <br /> Property Locapm <br /> l /l Mandan t Ave- A). Govt.Lot_ ___ <br /> City,Stt Zrp Code Phone Number <br /> /GorCt� �or/<�' H71V S"SOd.f Yy Yy Section <br /> IL Type of Building(che&all that a Lot <br /> ot/-44�! Tit/ k orc <br /> apply) t# _�_N; R / encEq(� <br /> ®I or 2 Family Dwelling-Number of Bedrooms o� Subdivision Npme <br /> Block# <br /> ❑PublidCommaeial-Dm«ibe Use <br /> D City of <br /> ❑State Owned-Describe Use CSMNumb« D Village of <br /> (Town of "' ..Sfr r S mf <br /> IIL Type of Permit: (Check gedy ane boa on tine A. Complete tine B H applicable) <br /> dg#� <br /> D New System lacementRep System ❑TreatmenVHoNing Talc Repheement Only ❑Otlner Modi�ratim t Existing System(explain) <br /> newal ❑PermitRevision ❑Ch eofPlum6er List Previous it Number and Date Issuedtion Change ❑P«rnLL Transfer t New <br /> Owner <br /> IV.T of POWTS Cam ert/Device• Check all t at a <br /> X Nm-Pressurized t-Ground D Prmsud d In-Ground D At Grade D Mo d>24 ie.of su0able soil D Mmmd<24 in.of suitable soil <br /> D Holdial Tack D Other Dispeeal Componssl(explain) D Pretreatment Devi=(=phm) j <br /> V• aVrMatmMt AreahtfmmanJ <br /> Design Flow(gpd) Design Soil Application Ra <br /> 3 d d te(gpdet) Dispersal Ares Required(at) Dispersal Area Proposed(at) I System Elevation <br /> -7 `/,�y yro q/.s <br /> VI.Tank Info Capacity t Total #of Mamrfachmrer <br /> Cragon Gallon Units e <br /> NMT HXming Tanks 1^ g C3'/ <br /> Septi c«noting Tank 7r9 1`$-� <br /> Deans Climber7'ro <br /> r°o ro/j <br /> VII.Responaibitily Statement-I,to undersigned,assume responsibgity for installation of the POWTS shown m the aft sciplaes, <br /> Plumb«'e (Print) plumber's Sigmat MP/MPRS Number <br /> None Business Phone Number <br /> /?/L/�• �„ �,•,t s ���,•�Q Diel r�.S/ li 7rr-�d 6- ell <br /> plumb«'e Address kauma,city,stat,Zip Code) <br /> �776d /51„a, 7sr Gve6s{rr dv� S9,g9J <br /> tv.d2i <br /> mUxOilIasumSgntureeer Given Reason for Deeid <br /> e?50"� $Mad 'o7 <br /> IX.Conditions of Appr WpCessmn for Disapprove► <br /> Aaaeh to aoapems plan for M systea am ssbsk m the Conary only an paper sea lei glass a la 111 <br /> small in <br /> she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />