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eommerce.wl.gov Safety and Buildings Division County <br /> a <br /> as 201 W.Washington Ave.,P.O.Box 7162 n2tk— <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co <br /> S C n$ n .) <br /> -- Department of Commerce r=' <br /> Sanitary Permit Application State Tsactton Nu be <br /> In a,coreance with s.Comm.83,21(2),W is.Adm.Code,submission ofjhis forth to the appropriate governmental -M� 1 <br /> unit IS required prior to obtaining a sanitary permit. Note: Applidation forms for stale-owned POWTS are Project Address(if different thanmiiling address) Q <br /> ,u'omuted to the Department of Commerce. Peratpml,information you provide may be used for secondary z�87` � <br /> Purposes in accordance with the PrivacyLaw,s. 15.04 1 m Stats.. J , ^ <br /> L Application Information-Please Print All Information z f itoKe <br /> PropemOsmer's Name Pest# <br /> Zl4+t4e, �AnALASEK Ef 4X E 7-02 -2-36-,4-03.5 K-0O2-1521 <br /> I'ropem Oaner's Mailing Address Property Location <br /> 13120 Zo'f ' Sr 14, ._. GovL wnLLot 2� <br /> If Cin,State Zip Code - Phone Number ' %, Section <br /> ] O�,Vf trcle on <br /> S LWu)ArtR mA 7/S' T 3�/ N: REor '�J <br /> 11.Type of Building(check all that apply) Lot# <br /> �I or 2 Family Dwelling-Number of Bedrooms z tZ-. 4) z Subdivision Name <br /> _ Block# - - - <br /> uHI:. un-mercial-Describe Use <br /> ❑City of <br /> State Owned-Describe Use /'-'CSM Number ❑,(Village of <br /> V3 ?4g Townof Iz4x5K <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> ❑New System Replacement System D Treatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> n. ❑ Permit Renewal ❑ Permit Revision D Change of Plumber D Permit Transfer to New List Previous Permit Number and Dam Issued <br /> Before.Expiration Owner <br /> I\.Tv e of POwTS S stem/Com onent/Device: Check all that apply) <br /> Nor-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in.of suitable son D Mound<24 in of suitable soil <br /> _ Holding Tank D Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> I.Dis ersal/frea[ment Area Information: <br /> Design Flow(gpd) Design Sail Application Rate(gpdsf) Dispersal Area Required(sO Dispersal Area Proposed(sF)- System ElevatiorYV��Gh� <br /> (000 , 858. 90 CrV9/.3"S e91 <br /> Vl.Tank Info - Capacity in Total #of Manufacturer <br /> Gallons - Gallons Units v <br /> New Tanks Ezlstena Tanks <br /> C 7, v iZ A A <br /> G. U vl w in µ <br /> scptico tent .750 ,500 <br /> o ,wzr+ri o>t JC <br /> nesint;Chamber <br /> lar <br /> \'11.Responsibility Staters t-I,the undersignin)(russunAresponsibiL4 for installation of the POWTS shown on the attached plans. <br /> P Vik'S€ft & EXCAVATION PI ber' S' ature MP/MPRS Number Business Phone Number <br /> Plum rIf <br /> pgt, �y, _ o e) <br /> e 9 <br /> VIII. County e artment se nl <br /> Approved 11 Disapproved PermPermitFee <br /> r Date Issued Issuin g ignature <br /> 11Owner Given Reason for Denial $ <br /> 3,2 J no JT•r1��('� <br /> IS. Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plana for the system and submit to the County only on paper not leAin ho in size <br /> JUL 1 20,1 <br /> SHD-63,98 (R. 01/07)Valid dim 01/09 <br /> BURNETT COU ► <br /> ZONING <br />