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coMRlerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 &k r h C ?If <br /> i s eo n s i n Madisom WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application Sae rma..ton um r <br /> In accordance with s.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental <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. Persona( information you provide may be used for secondary <br /> purposes n accordance with the Privacy Law,a.15. 1)(m),Slats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Gcr,- n, e t 03et - 7/aS-oayo0 <br /> Property Owner's Mailing Address Property Location <br /> 6607 t`/o,errs e Govt.Lot <br /> City,State Zip Code Phone Number Section <br /> Ok ii(ate v' W S Se g4 J aSl 6.56 76 7d(7 (circle one) <br /> E or� <br /> ,IutL Type of Building(check all <br /> T Y/ N; R 111 that apply) Lot# <br /> ItY 1 or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> Block# <br /> IV yI <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑y Village of <br /> In Town of Sw 0.xs <br /> III.Type of Permit: (Check only one boa on line A. Complete tine B if applicable) _ <br /> A. 052 a <br /> ElNewSystem OR lacement Sys ❑Treahnent/Holdin I _ _ <br /> Y 151 eP Y B Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change ofPlmnber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> rIV.Type of POYM S stem/Com ent/Device: Check all that apply) <br /> p Non-Pressurized In-Ground ❑Pressurized In-Grouud ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Preheatmmt Device(explain) <br /> V.DispersaYrmatmentArea Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdaf) Dispersal Area Required(sf) Dispersal Ater Proposed(at) System Elevation <br /> Sao . 7 N/,9 1 `ad 9 1 ?/- 4 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallon Gallow Units y o v <br /> New Tmks Exisdhg Tants u q B R ? <br /> Septic or Holding Tank 7.fO 7SG / W. G- I•? X <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPINIFRS Number Business Phone Number <br /> i2lc/--- fin lin 3 / . .� fid o(Jsgs-1 7/.<S6L-e,'is�> <br /> Plumber's Address(Streel,City,State,Zip Code) <br /> ,17 7 ro 0 Nrvy .?S— GI/ew.l SYr-F <br /> VIJIL Conn /De artment Use Only <br /> veil 1 ❑ Disservm <br /> eil Perit Fee /�''� Dy/a(t�e lseued Iasuin rnt Sigwluw <br /> ❑Owner Given Reason for Denial 1 S3 0�5 <br /> IX.Conditims of Approval/Reasons for Disapproval <br /> Attach m complolo plow for the system and submit tothe County only an paper not less tlw 8 is a 11 Inches lo alae <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />