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GOfrfercemi.gov Safety and Buildings Division ('manly <br /> 201 W.Washington Ave., P.O. Box 7162 Q� it", <br /> ( nsin Madison,W153707-7162 Sanitary PermilNumbei(obeGlledinbyColl <br /> part Ont of Commerce <br /> Sanitary Permit Application StateTfynsaelimnNan,bcr <br /> _ � I <br /> In ocg,rdanee With s.Comm.83.211 Wis.Adm Coda,submission of this Conn to the appropriate govummenml q}' Aluje.d -- <br /> unit i( re uirc 'I pilot to obtaining a sanitary omit. Note. Application forms thl' state-owned POWTS m <br /> 9 .1 g Y P PI a e Pro u.t Address' d Allluem than mai lin addss- <br /> ,I J ( 6 <br /> I� shbj)l)sC d'lo Cld mep�mment of Commerce. Personal <br /> l) infm'madun yuu pro,Ida may be used for aconalary <br /> iur nnu In acwnlanc wish the Nrisac Law,s'. ISA4(I)Im),Stats'. <br /> K Ao)likaticn Inlbiaation Please Print All Information / <br /> 1 r pully Owner's Nome / I'm cc]4 O7-©l <br /> "'o �Y► 7 // W q -5- aS- 00'/- 01'9poo _�I <br /> Piopeity Owner's Marailing Address Property Location <br /> (innlAmt --- <br /> C'itv,State y-� Zip Code p Phonc NNuum/beei / '/, Section <br /> 5 kr 611 `h' !O!9 �O(�✓J -(eircic oncL <br /> T I� �Bo YJ <br /> II.Type of Building(check all that appl)) Lola N; R <br /> �" l 2 Familv Dwelling Number of Bedrooms � Subdivision Nam <br /> ❑ Public(' <br /> / ommcrclal Describe Use Block <br /> .� <br /> ❑ C'ity ol'__ <br /> �' SM Num <br /> -s Ils'c Elillagc of <br /> te <br /> Iatc lly cscn __ --_ V3 <br /> Y6 QlowCK <br /> SB."Ij <br /> Ilk..'•i 04runitj (Cpcck only one box on line A. Complete line B if applicable) _ as 0 _ <br /> A WNew yscm1 Iteplacemenl System E 'frcutmenl/Ilolaling'I'onk Replacement Only ❑ Other Modification to FxisGng System,(explain) <br /> B. ❑ Permit Renewal ❑ pennil Revision ❑ Change ol'Phlm6er ❑Permit Transfer to New <br /> List Previous Permit Number and Dune Issued <br /> p ner <br /> I Before I)x folion Ow <br /> I I y )e of WTS System/Component/Device: Check all that apply) <br /> I� Son-Pfessm uod In��irotmd ❑ Pressurized In-Ground 11At-Gmdc F1Mom,d>24 in.ol'swatta,coil ❑ Mound<24 i ,1 su'tabk.slid <br /> Ll l ludding Tunk ❑Other Dispersal Component(explain)_ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsQ Dispersal Arca Required(sl Dispersal Arca ProSystem F. <br /> posed(sl) levstwo <br /> oo , -7 Yap so 9700 <br /> Tank ln(n C'upacib in Total aof Manu(adurcr <br /> --i- -- - <br /> Gallons Gallons ('.nits ° v <br /> New banks nxistiny Tanks m c - <br /> d <br /> Septic nr l ldd i <br /> VII. Responsibility Statement- 1,the undersigned,assmne responsibility For insmllation of the pOei'rS shown on the attached plans. <br /> Plumber's Name(Print) Plumher's'Signature —T Mli'MI'I25 Number Business Phone Nwobcl <br /> �� <br /> � eJ Fs�nlrnl Gam_ zz�'6gyy 72. 6 <br /> I'lamhar'slAddncss(Stmt.Cry,Suite /it)('odc) <br /> ----- -- -- 1 -- - <br /> S��7oZ <br /> 'tililbepaitnient use Only __ <br /> A)rprmbcd ❑ 17isappmred I'elm it Pae 15'f�vcd ksuin,,A, 1 ,ulure <br /> ❑ Owner Given Reason for Dental „V�v/� /`� • /'M1z�� <br /> Ik.Conditions of Approval/Reasons for Disapproval <br /> l <br /> I�i I S <br /> Attachto vulblt,te pia ,t'ur tha hnaid eatnmt n til('nuoc „h lupr li, hoo"T� lliulec i,eixc <br /> SBD-6798(102/09)Valid that 02/11 <br />