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commerceml.gov Safety and Buildings Division County <br /> 201 W.WaslingtonAve.,P.O.Box 7162 8krnElt•% <br /> iseo n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be£died in by Co.) <br /> Department of Commerce SZ 2�/ /' 1 � <br /> Sanitary Permit Application State TransactionNumber \� <br /> In accordance with a.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 me 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. 1(m),Stats. � � i <br /> I. Application Information-Please Print All Informon atin^ <br /> Property Owner's Name Parcel# v`9 <br /> /7"n w.. r 3�g 9go <br /> Property Owner's Mailing Address Property Location <br /> /•I3 3 y De v, P�r1, RV- Govt.Lot <br /> City,State Zip Code Phone Number Yy Yy Section /0 <br /> (]A n 6 a+,v Lt/1 S'a/87 0 lis- �.,sq_3o v el (circle one <br /> IL Type of Building(rheck all that apply) Lot H T qO N; R /S E o <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# q � �V <br /> D PubadCommercial-Describe Use <br /> D City of <br /> D State Owned-Describe Use CSMNumber ❑Village of <br /> Town of Jati k.Se rt <br /> IIL Type of Permit: (Check only one boz on Ihte A. Complete line B V applicable) <br /> A. D New Systcm eReplacemenl System ❑TreatmenbHoWing Tack Replacement Only ❑Other Modification to Existing System(explain) <br /> H. D Permit Rmcewal D Pemdt Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dam Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ®Noo-Pressurized In-Ground D Pressurized In-Ground D At-Gide D Mound>24 in.of suitable soil D Mound<yt in.of suitable soil <br /> D Holding Tank D Other Dispamad Component(explain) O Pretrestment Device(explain) <br /> V.Dis ersaYrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Arm Required(sf) Dispersal Area Proposed(af) System Elevation <br /> yr0 r 90 0 Sao 90. 7 <br /> VL Tank Info Capacity in Total p of Manufacturer <br /> Gallons Galloon I Unita o <br /> a <br /> New Tanks Fxistirrg Tarks 3 5 $s 11 .lo <br /> m rn 'ti C7 P. <br /> Septic or Bolding Tank /ot.T0 /e(SO ) fA/. C• F? X <br /> Dosng Choate, <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber',Signature MP/MPRS Number Business Phone Number <br /> )2 2 e_ le- /510le,"f / ,dQ !� o SCSI 7iS- X66—y/s7 <br /> Plumber's Address(Street,City,Stam,Zip Code) <br /> 7760 lela. 3S VV-f ltit Sy 893 <br /> IL Caen /De artment Use Oul <br /> roved D Disapproved Permit <br /> -F�m Date Issued <br /> �.(`� Isauhr gem Signature <br /> D Owner Given Rots=for Denial s�W'IJ IJ III�D�V25 ` <br /> IX.Conditions of ApprovaURessons for Disapproval <br /> Amaeh to romplen qw for the syateas and wbmn m th Coumy only m paper not leas than a 19 a 11 inch.m at. <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />