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co111Rlerce.Wl.gov Safety and Buildings Division County nn <br /> I f <br /> 201 W.Washington Ave.,P.O.Box 7162 att n e <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce S21 175 <br /> Sanitary Permit Application Stare Transaction Number <br /> In accordance with a.Comm.8311(2),Wis.Adm.Cade,submission of this form to the appropriate governmental rV/A <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-awned 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,a.15. I m),Stats. <br /> I. Application Information-Please Print All Wormation h I S'$4 <br /> Property Owner's Name f Parcel# <br /> FF /Z 6"M K/averK 0o6 dwell a16o0 <br /> Property owner's Mailing Address Property Location 5175' Of N 2?5'Ly+u4 <br /> 3I J 9 /c%l herb o C Sr N6 Govt Lot 3 (()OF <br /> Aura/ TU <br /> City,State Zip Code Phone Number y, Y., Section _ <br /> 15 f"traH . 54-6-4/or T 38 N; R_�E or&' <br /> IL Type of Building(chmk all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commwcial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number DVillage of <br /> (Town of 04 <br /> IIL Type of Permit: (Check only one box on One A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatmmt/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> B. ❑Pormit Rarewal ❑Permit Revision D ChangeofPlumber ❑Permit Tranferto New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS stem/Com ent(Device: Check all that apply) <br /> D Nw-Pressurized loGrouod O Pressurized In-Ground O At-Grade D Mound>_21 is of suitable soil D Mound<24 in of suitable soil <br /> 4 <br /> $Holding Tank D OtherDispasal Component(explain) D Pretreatment Device(explain) <br /> V.Disowenalfrmahnent Ares Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdat) Dispersal Area Required(eE) Dispersal Aron Proposed(af) System Elevation <br /> — <br /> VI.Tank Wo opacity in Total #of Manufacturer <br /> Gallon Gallons Unita <br /> New Tanks Twisting Tanks <br /> Septic or Holding Turk <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana <br /> Plumber's Name(Print) Plum'ber's SSignature� MP/MPRs Number Buineea Phone Number <br /> /c/L J/o <br /> kin 1 <br /> -'1Z--ber's Address(Street,City,State,Zip Code) <br /> ,t 7760 ,5..y 3S-- uv-ebstr W-F-- .5 W73 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Pemut Fee Date Issued Issuing Agra2turo <br /> D OwnerGiven Reasonfor Denial $375-P '�� O"q <br /> DL Conditions of Approval/Reasotu for Disapproval Note: -thee, k F Ne ,,rr�-'' �J <br /> M'aaa k_ S,ar Ie flea. for e a.MC Soy( <br /> A{atee/4n C.U. <br /> Attach to complete plum for the system and submit tithe Counly only m paper not tees than 8 M a 11 mehes in she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />