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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 57tt pe N E f r <br /> isco n s i n Madison.WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of commerce LY i 1 2 rl. <br /> Sanitary Permit Application Stat`a Trr action <br /> Number (`��`c) \ <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental r/ i <br /> unit is required prior to obtaining a sanitary permit. Note: Application turns for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary. A / <br /> uses n accordance with the Privacy Law,a.15.04(1)(m),Stats. <br /> I. Appilicationlnformation-PleasePrintAllinformation <br /> Property Owwner'$Name / �^ /}L/- Parcel# <br /> DA.Vif w tJK Ile /ZQ(aMB V � O/-000 '//✓AO <br /> Property Owner's Ma <br /> il <br /> ring Address Properly Location ,II5CO",/ /Jor(d,W1 sf <br /> �.t ,ter <br /> �B 70 /•t /.$.$*(AP. 1 /vie Govt.Lot /J yfj&,, RI✓Cf <br /> City,State Zip Code Phone Number <br /> Al2W W J�+ <br /> / �W* cellT yo N. R /bcnclE ane)_ <br /> aI,L(Type of Building(check allot that apply) L # d�7 <br /> ,O i or 2 Family Dwelling-Number of Bedrooms W Subdivision Name <br /> Block# <br /> ❑Public/Commemiai-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSMNumber ❑p Village of <br /> Town of CA /G/arN Of <br /> Ill.Type of Permit: (Check only one boa on Bne A. Complete line B if applicable) _ _ _ OD <br /> A. <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change List Previous Permit Number and Datelssued <br /> ang ❑Permit Transfer to New <br /> Hefore Expiration Owner <br /> IV.Type of POWTS stem/Com mmVDeviee: jCheek an that apply) <br /> PS Nov-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 im of suitable soil ❑ Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersArfreatment Area Information• <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requved(af) Dispersal Area Proposed(sf) System Elevation <br /> Goo '7 ;Vr 1 8fiy 9y-� 9�• c� <br /> VI.Tank Info Capacity in Total #of Mamrfacbw <br /> Gallons Gallons Units ° <br /> New Tmrks fizisting Tmdcc <br /> A <br /> No re <br /> Septic or Holding Tank /j S O <br /> Dosing Cumber s/G/t a✓ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Pl'u�mber'a�Signat MPMIPRS Number Business Phone Number <br /> R,e-/L o / r H -Jr Imo` (� p�l f�S / TJ- g(r6�4'/$-.7 <br /> Plumber's Address(subet,City,State,Zip Code) <br /> d776a /S/.. 3f tf/�/as7�lr� wy� S`/`�53 <br /> VIII.Court /De artment Use Ont <br /> Approved Disapproved <br /> Permit Fee Dilate Issued las ' A t Signature <br /> ❑Owner Given Reason for Denial S 3 8 AJ 20 <br /> 1 <br /> IX.Conditions of Appros W,Reaaons for Disapproval <br /> Attach b eomplefe plam for the system and wbmit[o tk County ady ov Aper mt tem Wan B 1rz:111mehea In size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />