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COff1ITlefC@.W1.g0 <br /> V Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 �u n <br /> 'Wisconsin Madison.W1 53707-7162 SxuihryP tNumbm(to be fdled in by C.) <br /> t>apamrmm of Cammerca 49 +84? <br /> Sanitary Permit Application State T`apnaae on Number <br /> In accordance with a.Comm.8321(2),Wis.Adm.Cade,submission of this form to the appropriate governmental /30 L 149 n l <br /> unit is required prior to obtaining a sanitary peon, Note: Application forms for state-owned POWTS are Project Add a(if differmat(Lara mailing address) 1X/JI <br /> submitted to the Department of Commerce. Persona( information you provide may be Deed for secondary <br /> ees in accordance with the Privacy Law,a.15. ] m),Stab. <br /> L Application Information-Please Print All Wormation dY073 d8073Jahmre n J k- /?d- <br /> Property Owner's Name Parcel 8 <br /> 8/ens Sw.tnrnn o} - u3,13 oG y/o <br /> Progeny Owner's Mailing Address Roperly beta'on <br /> 3 o.SSo ./d ri.,r P ftp e 30l Govt.Lot <br /> City,State Zip Code Phone Number 55, Yy Section a)3 <br /> ROSe vi lie pili/ SS/).3 '/d R l6(crce me) <br /> T <br /> IL Type of Building(check all that apply) Lott! I o& <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision N me <br /> Block A N�t l r <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Va to f L?Town of Oa4k/t n.' <br /> Ill.Type of Permit: (Check only one box on fine A. Complete fine B if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tack Replacwwt Only ❑Other Moth rcatian to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision El change of Plumber ❑Permit Transfer to New <br /> List Previous I crmit Number and Date Issued <br /> Before Expiration Owner <br /> IV. of POWTS stem/Com mt/Device: Check all that apply) <br /> 11 Non-Pressurized In-Ground 11Resaurized 1mGround ❑ At-Grade ❑Mwnd>2A in of suitable soil 'ableand<2 tin ofsuitable soil <br /> ❑Holding Tank ❑Otho Dispersal Component(explam) ❑Pretreatment Device(explain) <br /> V.Di ersal/1'reannent Area Infarmatim: <br /> Design Flow(gpd) Design Soil Application Rate(gpdat) Dispersal Ates Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 300 9 300 333 97. 7.4 <br /> VI.Tank hdo Capacity inTotal N of Manufacturer <br /> Gallons Gagons Unita yq o u <br /> New lards Fixrsnng Tanks `n 'Q7 ,y y a <br /> Septic a HoWing Tank <br /> Ibmg Chamber S-o0 S"o0 <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the atted plans <br /> Plumber's Name(Rin() Plumber's Signature MP/MPRS Number Bnsinese Phone Number <br /> Rje filo / / � /s-X66-v/s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> at -776a .41;,. v - zv -5`893 <br /> VII Coon /De artsnmt use Only <br /> F?rApp..d ❑Disapproved Permit I= DateIssuedIssuing rgrumre <br /> 11 Own=Given Reason for Denial �o t 16 04 V 07 <br /> IX.Cmditimts of Api rwal/Ress sas for Disapproval <br /> D )3 �. <br /> Attach to eempkte plans forth syatrw and sabots to the Ceenty only on paper Det has xlthKho ..be <br /> 1t1 Y 1 2007 <br /> SBD-6398(R.01/07)Valid thru 01/09 BURN TT COUNTY J <br /> ZONING <br />