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commememl.gov Safety and Buildings Division County T�/ [�� <br /> 201 W.Washington Ave.,P.O.Box 7162 (,r KY T W <br /> sco n s i n Madison WI 53707-7162 is Permit Number(to be filled in by Co.jW <br /> triollpirbMtolconnem 53z 17$ <br /> Sanitary Permit Application State Transaction Number 60 <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental P.(Irk <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS areProject Address(if different than mailing ad <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. e <br /> L Application Information-Please Print All Information a /�f/1 T11I Q ✓COSI Q <br /> Property Owner'sName ` Parcel# <br /> v d /—OL +S0-- -4'2 o-D (000 <br /> Property Owner's Mailing Address Property Location <br /> W019 01 e t (PV Govt.Lot <br /> City,Stale Zip Code Phone Number '/., A, Section S <br /> I,f r KQ 'J 1-e PH " sS 3D 6 I L 7S 1. 4 3 69 � (circ/le one) <br /> H.Type of Building(check all that apply) Lot# T yD N; R j#W <br /> ®I or 2 Family Dwelling-Number of Bedrooms 3 Ll Subdivision Name ��//''❑ ��- Ke KC/ Sri dit/Public/Commercial-Describe Use Block# CU '! <br /> ❑ city of <br /> ❑ State Owned-Describe Use CSM Number ❑ Village of <br /> ® Town of S C-0„�+ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _Qct _ _ - _Q <br /> il <br /> A. ❑ New System Replacement Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain <br /> System <br /> B. Permit Permit Revision Change of Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber TNew Owner <br /> Expiration <br /> IV.T e of POWTS S stem/Com onent/Device: Check all that a 1 <br /> Non-Pressurized In-Ground Pressurized In-Ground At-Grade ❑Mound>24 in.of suitable soil C1 Mound 124 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> DesignFlow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> fT/V O "7 y 3 &s—p Z. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units m o g <br /> 6 U <br /> New Tanks Existing Tanks zo W F m e3 <br /> U C m <br /> Septic Holding Tauk �( 1000 t w l e Se LXJ ❑ <br /> Dosing Chamber ❑ 11 -0- 1 L <br /> r <br /> VII.Responsibility Statement- I,the undersigns ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI tier's Nam (Print) Plu bet's Signature MP/MPRS Number Business Phone Nu tier <br /> ens r 2ZS22 WE 66-Y6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -1 g q sS 60"±11 <br /> VIIII.County/Department Use Only <br /> _ Approved _ Disapproved Permit FeeL' Date Issued Issuing Signature <br /> _Owner Given Reason for Denial $ n'C` 1p / 0 <br /> 9 <br /> IX.Conditions of Approval/Reasons for Disapproval Jo <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/22 x 11 inches in size <br /> SBD-6398(R-01/07)Valid thru 01/10 <br />