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convnerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 all,r h � <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled In by Co.) <br /> Departmm <br /> ent of ComQerce as <br /> Sanitary Permit Application State I on Numbe �J <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental H Ute <br /> unit is required prior to obtaining a sanitary permit Note: Application forma for state-owned FOWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. personal information you provide may be wed for secondary <br /> ees in accordance with the Priv Law,a.15.04(1)(m,Stats. / <br /> L Application Wme thn-Pleax Print AS InformaStion 3AA? rrn Green (.Uaey <br /> Property Owner's Name Parcel# <br /> /fir th grebe( � , 3q Qx� 07-0220-4- 9b-N-0-7-5 islb�-a2/ <br /> Property Own"a Mailing Address <br /> ` Property Location <br /> , 5056 Loon (31o'ta Sable �icck,�dhtgn nr 8� GwtLnt <br /> City,state Zip Code Phone Number <br /> Section 7 <br /> l /A /torr Wr -548 43 (cycle one <br /> tILf Type of Building(check all that apply) Lot# T yO N; R /4 E o <br /> p 1 or 2 Family Dwelling-Number of Bedroom —7 34 subdivision Name <br /> ❑ V,Public/Commercial Use <br /> Block# `nJ <br /> V, <br /> ❑ ity of <br /> El state Owned-Describe Use CSMNumb" [I Village of <br /> Town of -<4-0 7/ <br /> Ill.Type of Permit: (Check Only one boa an line A. Complete line B if applicable) _ _ _ <br /> A. ❑New System RReplacement System ❑ TreatmenbHokiing Tank Replacement Only ❑ Other Modification to Existing S 17 <br /> ystem(explain) <br /> B. ❑Permit Rewwal ❑Permit Revision ❑Change of Plumber ❑permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S smm/Com onent/Devim: Check all that apply) <br /> A Non-Pressmaed In-Ground ❑Pr"surized In-Grormd ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Bolding Talc ❑Oth"Dispersal Componunl(explain) ❑Actmafmcut Device(explaiµ) <br /> V.Dispersob7treatin Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdat) Dtpersal Area En <br /> a proposed(a System Elevation <br /> . 7 G VL Tank Wo Capacity in TotalerGallons GallonsNew Tanks Existing Tanks 'O V is <br /> rS Sep[ie w xnlding Tmdc ,t/ <br /> Dosing Clamber <br /> VII.R potability Statement-1,the undersigned,assume rapo sibility for installation of the POWTS shown an the attached plans. <br /> Plumber's Name(Print) Plumber's Si alure <br /> � MP/Iv1PRS Nrmber Iwin"s Pham Number <br /> /?/Llc /7�0 /4'n S 1 ..Q f� �l SBs� 7�r_ X66- vis> <br /> Plumber's Address(Smoot,city,Stm,Zip Code) <br /> a 7 76 0 /sou .3s W.e6sr4.� <br /> VIIL Corm /De armaent Ux Ont <br /> ❑ Approved ❑Disapproved Permit Fm Dam Issued las ' Sigwtme, <br /> ❑Owner Given Reason f"Denial 09 <br /> IX.Condidms of ApprwaVReasmts for Disapproval <br /> Anach on co ophte plan for rh Vaasa and serum an the County may on paper not has than 8 in x 11 Inches in aim <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />