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ON COMPUTER/SCANNn <br /> tcommerce.Wl.gov Safety and Buildings Division County <br /> a 201 W.Washington Ave.,P.O.Box 7162 <br /> i sco n s i n Madison WI 53707 7162 Sanitary Permit Numyer(to be filled by Co.) <br /> Department of Commerce �Ci/v ,/i f D <br /> Sanitary Permit Application Stale�T/g pYac/tion Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental V WN v7 1Qe.U1uJ <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different than nada g address) ((� <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes m accordance with the Privacy Law,s.15.04(1)(m),Stats. A ;7 <br /> I. Application Information-Please Print All Information- V7ZIell ReiLr /2!.4 <br /> Property Owner's Name Parcel#O'7 Od b d 40 /(r <br /> IDan 43ar-. /Aa1 3 of S' 6(Aisdo <br /> Property Ownm's Mailing Address Property L-ation <br /> YNS Gvicen hA L,e- vr. <br /> Ci State Govt.Lot <br /> lY. Zip Cade Phone Number <br /> V A deA h IJ /Yl N Y., Y., Section <br /> .�5�� S.r/d 7 (circle one) <br /> IL Type of Building(check all that apply) I,ot# T qO N; R /0 E oro <br /> 91 or 2 Family Dwelling-Number of Bedroom. Al Subdivision Name <br /> Block# <br /> ElPubkdCommercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Q Town of /c/al at�• <br /> [IL Type of Permit: (Check only one boa on line A. Complete line B if applicable) _ <br /> A. 0 New System y ❑Replacement System PrTreatmrnUHalding Tank Replacement Only ❑ Other Modification to Existing Static (explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑ Cbange ofPlurnber ❑Permit Transfer to New List Previous Permit Number and Date I sued <br /> Before Expiration Owns <br /> IV.T e of POWTS 5 stem/Com onent/Device: Check all that apply) <br /> �C <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 Al-Grade 0 Mound>24 in of suitable soil Mound c 24 in.of aui ble soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dis ersaUTreahncut Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> .3 00 1 — — — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units y <br /> New Tanks Existing Tanks w rte U $ <br /> u <br /> cC.U in w 'ti C7 6, <br /> Septic or Holding Tank 7S'0 7S 0 <br /> Dosug Clamber S••00 SOO <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> // l� MP/MPRS Number Business Phone No, ber <br /> R Ic/c Ne /cr n S I er,,r // /Vsf r1 ��s• Ste/` �/i-r7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 7 6 152 /"/, ;, W e6 s{t i 4, a <br /> �VHL Cou7117GZ1wn7ivm <br /> latent Use Onl <br /> li ApproveDisapproved Permit I= <br /> Date Issued Issuing g Signature <br /> Reason for Denial 8 .3a.S�to 24, IL 01' <br /> IN.Conditions of Approv"measons for Disapproval <br /> ��l M.pf mdtccfe 3L38, AlaH�amai{i .loa•..� � A�zccx- dv g,�tn.V�lht ,fferaa�,'t, Cery�/qc <br /> Atmeh to compete plan for me system and submit to the Comely Only on paper not leas than 8 in s 11 inches in sire <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />