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commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 (3a r it l� <br /> is e o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce 53Z/5'B <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83:21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental 6ft'neul e'4 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms 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 secondary p/'r 2 �h�y ./1 I�G1�O F <br /> purposes in accordance with the Priv Law,s.15.04 1 m,Stats. O TJ <br /> I. Application Information—Please Print All Information ( IJ <br /> Property Owner's Name Parcel# `J <br /> TIM wrd; la« odto- a3ir- ofg00 <br /> Properly Owner's Mailing Address <br /> Property Location <br /> 8/ y 3 G•o 7ed u• r I OZ. <br /> City,State Zip Code Phone Numher <br /> W/j, SW '/., Section r 9 <br /> I U•ek-'s- e ✓ 2vT SY893 r HO N: R �P Eon <br /> II.Type of Building(check all that apply) ff Lot# <br /> 01 or 2 Family Dwelling-Number of Bedrooms A Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> ❑City of <br /> 11 State Owned-Describe Use CSMNumber 0 Villageofs� <br /> JS To"of lJJ� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ,®Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision 0 Change of Plumber 0 Permit Transfer m New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> R Non-PressuriuA InGround 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dis ersaIrrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(Wdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 S 600 600 9 3•d0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units g�+ <br /> New Tanks Existing Tanks C U 15 ir <br /> Septic or Holding Tank <br /> 7�Sa 7J'O � LdICS C� <br /> Dosing 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 Signature MP/MPRS Number Business Phone Number <br /> 2,e- #0 r-,r?f I a,sss/ pis-�66- vrs> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,177 , e Irmo. 3.� Lve6s <br /> VII Count /De artment Use Only <br /> IM Approved 0 Disapproved Permit Fee Date Issued Issuing A S' ature <br /> 0 Owner Given Reason for Denial S 3Z O ZT yVat 09 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Fiow s Loect Aff &460ir T 6e Racoma . <br /> Attach to complete plans for the system and submit to the County only on paper notices than 8 to x 11 inches in size <br /> SBD-6398(R.02/09)Valid thou 02/11 <br />