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COIt1MOfC• 9GV Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 13" r n g <br /> SwO nes'� Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> V 521 / '7q <br /> State Transaction Number <br /> Sanitary Permit Application <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. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy law,s.15.04(1)(m),Slats. G'O �d i <br /> I. Application Information-Please Print All Information l i <br /> Property Owner's Name Parcel#036 44ed3 o1 700 <br /> JrM [Jrachw..++e <br /> Property Owner's Mailing/Address Property Location <br /> to s Hi �!J il�t ✓'• Govt.Lot Z <br /> City, Zi Code Phone Number ''/4, '/4, Section a 3 <br /> Ci State p (circle one) <br /> LCa „ In 'V 'S 3�°t T 4(0 N; R 0- <br /> 4' w - <br /> II.Type of Building(check all that apply) Lot# <br /> 7X 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> of un/Ch <br /> III.Type of Permit: (Check only one box on line A. Complete line B if gpplicable) <br /> A. New System Replacement ElTreatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> System <br /> B. Permit Permit Revision Change of Permit Transfer to <br /> List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> Non-Pressurized In-Ground Pressurized In-Ground At-Grade Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsp Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> -/s 0 . 7 6 l 6q6' 9t ap a 93 a0 <br /> VI.Tank Info Capacity in Total #of Manufacturer m o <br /> Gallons Gallons Units a U U k N <br /> N <br /> New Tanks Existing Tanks O tiIta <br /> Septic or Holding Tank /see /O/D <br /> Dosing Chamber 600 G 0/ <br /> VIL Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa_ ture MP/MFRS Number Business Phone Number <br /> R/ck- • klr -1 ,t7,t� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ej7760 yl�. y 3Sy wombs-/-e - k/ -"893 <br /> .Coun /De artment Use Onl <br /> Approved _ Disapproved Permit Fee Date Lssued Issuing `gnature <br /> _Owner Given Reason for Denial $ 2 /0 11 anck 09 <br /> IX.Conditions of Approval/Reasons for Disapproval✓ /�� <br /> Attach to complete plans for the system and submit to the County only on paper not less times lax 11 inch"in sin <br /> SBD-6398(R.01/07)Valid thlu 01/10 <br />