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commerce.wl.gov Safety and Buildings Division County <br /> 201W.Washington Ave.,P.O.Box 7162 /3'k NA CV` <br /> i seo n s i n Madison.Wl 53707 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 'f // 2 <br /> Sanitary Permit Application Sa/efr' saction Nyumber ` <br /> In accordance withs.Comm.83.21(2),Wis.Adm.Code,submission of this forrn <br /> m to the appropriate govemental L f2(Jlet.t,) <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned 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,s.15.04 ixm),Slats. / ) <br /> I. Application Information—Please Print All Information .7 7950 *14k) �dKe 4 <br /> .1. <br /> Property <br /> �-7Owner's Name Parcel 4 e-r-m-T - O <br /> /PA'f- v/`I t P e <br /> Property Owner's Mailing Address 05-- 0oc O/S�0 <br /> Property Location W 798' of F,eSE /310', <br /> A 77Sp 'sti//ery Glc (wry ) <br /> '�� ' Gov[.Lot �reatteU <br /> City,State Zip Code Phone Number Y., Yti Section <br /> k/ie bb f-r (n/r j"y 6ri 3 (cacle one <br /> IL Type of Building(check all that apply) Lot q <br /> T� N; R1�Eor� <br /> JA I or 2 Family Dwelling-Number of Bedrooms r;04 Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number El village of <br /> ®Town of <br /> IIL Type of Permit: (Check only one box on line A- Complete tine B if applicable) <br /> A. ❑New System ,[�Replacement System ❑ Treatment/Holding Tank Replacement Only I ❑ Other Mod cation to Existing System(explain) <br /> B. ❑Permit Renewal ❑ PermitRevision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ❑Non-Pressurized In-Gmmd ❑Pressurized In-Ground ❑At-Gradc ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 300 — — <br /> VI.Tank Wo Capacity in Total N of Maaufacturer <br /> Gallons Gallons Units 'Soy v <br /> New Tanks Kestiug Tmiks e U u — b ® ii, <br /> c 3 E + m <br /> Septic or Holding Tmdc /"L d./ "' .33.•f., .f/C w ✓ <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si� MP/MPRS Number Business Phone Number <br /> /lie-/c u /4/tis <br /> Plumber's Address Street,UAY,State,Zip Cade) <br /> 77 r 3.�2v�bs �tri `/fBSJ <br /> III.Cour /De artment Use Out <br /> Approved ❑Disapproved PurmiI F= Dam Issued Issuing Agem Si lure <br /> ❑Owner Given Reason for <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Nora: 5&V&6vee, a,a( FIoLCt.iy T.K Joce£ro t are not l Ue,cdfu! <0 6 <br /> eF ya!ltW ,take o- i�Ae P(RM fur t2urneft C: A. 44 A1`214W ;49"f /9, <br /> Attach to complete plans for the system and submit to the County only on paper rot lea than a in x 11 inches in sire <br /> SBD-6398(R.01/07)Valid thry 01/09 <br />