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co'"merce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> t[s eonsi n Madison,WI 53707-7162 Sanitary P/erm/it Number(to b filled in by Co.) <br /> rtmem of comm m. �l0 b 7-;,, <br /> Sanitary Permit Application gib" <br /> In accordance with a.Contra.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental 410"1 AN 0/8 33.2¢ S/00 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forts for state-owned POWTS are Project Address(if different th n mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary / <br /> purposes in acmrdaoce with the Privacy Law,s.15. 1)(m),Stats. Pe C✓'JO <br /> I. Appilemion Information-Pteme Print All Information fil OUV71 <br /> Property Owner's Name parcel# <br /> mo,, 03� s0 -0//000 <br /> Property Owner's Mailing Address PropertyLocatim 01`33- 'a((--05-1 (Y <br /> Gds e—fOVe/ls/r p4ex we'Y C'*Wet 15mr As fW1 <br /> City,State Zip Code Phone Number :SCOyh y�YS Swion w <br /> Ea In A/ S.S-/�.3 (aS/- 4S6 4dlS T 39 N; R /(.(cvc oneZ <br /> IL Type of Building(check all that apply) Lot# r� <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commereial-Deambe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number D Village of <br /> Q To"of /Y/a v. Ort <br /> IIL Type of Permit: (Check only oue box onlite A. Complete line B if applimble) <br /> A. <br /> New System ❑Replacement System ❑TmatmemiHolding Tank Replacement Only ❑Other Modification to Exist g System(explain) <br /> B. ❑Permit Reawal ❑Permit Revision ❑ Change of Plumber ❑Perms TnmfermNew <br /> List Previous Permit Number a ad Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS tem/Com onrnt/Device: Check all dist apply) <br /> ®Non-Pres ..d I.-Ground D Pressurized Lt-Ground ❑At-Grade ❑Manuel>:24 in.of suitable soil ❑Mound<yy in,of suitable oil <br /> D Holding Tack D Odmr Dispersal Component(explain) D Retreatment Device(explain) <br /> V.DispI aVfreahneaat Area hiformation: <br /> Design Flow(gpd) I Design Soil Application Rate(W&f) I Dispersal Arm Required(d) Dispersal Area Proposed(af) System Elm Ition <br /> yrs . S 900 900 9 S <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units y r <br /> Nev,Tanks Exahng Tanks is <br /> SepticorHokingTack /000 X800 <br /> Doing Chamber (o0p OO <br /> VII.Responsibility Statement-I,the undersigned,assume responsibaHy for installation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) I Plumber's Signature MP/MPRS Number Business Phone Number <br /> ,*�'/e_le- /1/ole/H �tds 8r 7/.r- S6&-'//s� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 760 w as wccs err rtir sl�6'43 <br /> I Com /De armtent Use Only <br /> Approved ❑Disapproved Penniiff es xa� Date Issued Issuing rgnatare <br /> ❑Owner C&=Reason for Denial s"JD"r•O !l �G 6 <br /> IX.Conditions of Appa o ad/Remains for Disapproval <br /> Attach to complete plain for the system and vtbdt to the County only on paler not has than 8 rrr a 11 Inches ta sire <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />