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commerce.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 13 u r A Lo <br /> �j f i s eo n s i n Madison,Wl 53707-7162 Sanitary Permit Number be filled in by Co.) <br /> Department of Commerce 5,z/ l 70 <br /> Sanitary Permit Application State Transactiofn/Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental /V A <br /> unit is required prior to obtaining a sanitary permit Note: Application fors for stmerowned POWTS are Project Address(ifdifferenl thanmadingaddress) <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.15.04(1)(m),Stats. / /i <br /> I. A lication m <br /> Inforation-Please Print All Information G'1,i t ;. �`A S 7 ly C o /7Gl 7 <br /> Property Owner's Name Parcel# <br /> ,,rte /-/wnd f, Clio( - JS33 - oil you <br /> Property Owner's Mailing Address Properly Location <br /> 7S-6 0 L.rc 0 o h L a s e Govt Lot <br /> City,State Zip Code Phone Number <br /> NW y., $N/• ys. Section 33 <br /> Web.5l'-e - wZ Syggg 7/S- $6/0 soeIV (circle one) <br /> IL Type of Building(check all that apply) Lot# T 3 8 N; R / 5' E onS) <br /> 53 1 or 2 Family Dwelling-Number of Bedrooms d Subdivision Name, <br /> Block It <br /> ❑Publie/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 'Town of L✓00 d /Zr✓ e <br /> IIL Type of Permit: (Check only one box on Ibhe A. Complete line B if applicable) <br /> A. <br /> ®New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Peru Renewal ❑Permit Revuiom ❑Change of Plumber ❑Permit Transfer tu New List Previons Penh Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS 5 stem/Com onent/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> le Holding Tank ❑Other Dispersal Component(explain) ❑Pretiea num[Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 3 ,0 — -- — <br /> VL Tank Info Capacity in Tout #of Manufacturer <br /> Gallon, Gallon Units o$ u <br /> �^ _ <br /> New Tmda Exca ng Tanks �ea v ° q m <br /> Septic or Holding Tank 3000 30&0 / f/G atw x <br /> Dosing Chamber <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 Signature MP/MPRS Number Business Phone Number <br /> R /c /7/6/0/c�H s /cryo-r�� f/ ,l J.-s-'frS" 1 7/s-8GG - v/s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77 e. O 3 s t4,/ .Sy 8 9'-? <br /> V111.Count"/De Use Only <br /> Approved ❑Disapproved I�= I ate lsAAsued Issuing Ag rgmture <br /> ❑ Owner Givev Reason for Denial SL�LIo /V(U. VU <br /> IX-Conditions of Approval/Reasons for Disapproval <br /> ABach to eomplent plans for the system and submit to the County only an paper not has than 8 in x 11 inches Is star <br /> SBD-6398(R.01/07)Valid flum 01/09 <br />