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Cornmercemi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Stn r h ietDaparbiwerst i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> or Canmerce -5-Z/ 076 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.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: Applicatimh forms for state-owned POWTS are ProjectAddress(if different than mailingaddrese) <br /> submitted to the Department of Commerce. Personal information you provide may be wed for secondarypurposp= n <br /> es is accordance with the Priv Law,s.t Ali nfisr Stats. ,28383 _ 1'pA Ito AD yt 1 1 <br /> I. Application Information-P►esse Print All Information ✓� �./ <br /> Property Owner's Name Parcel q <br /> o <br /> �,{_ � old a v( 1s d v 1e y <br /> L71-'i e--A? ,713 313 moo &11,10( Z <br /> Property owner's Mailing Address Property Location <br /> 8383 /oh Bin /zap• Govt Lot <br /> City,State Zip Code Phone Number y,, NE yy Section 01 y <br /> W gh-5fee WS 15"" 193 7/S- 8G6- 7Sy7circle one <br /> IL Type of Building(adamit all that apply) Lot# N; R /S E o <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑PubadCommercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> Town of )A, <br /> Ill.Type of Permit: (Check only one box an tine A. Complete tine B if applicable) <br /> A. ❑New System XR lacement g Tank System ❑Tmatment/Holdin <br /> W Y Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Chan a of Plumber List Previous Permit Number and Date Issued <br /> B. El Permit Renewal ❑Permit Revision g ❑Permit Transfer to New <br /> Before Expiration Owner _ <br /> IV.Type of POINTS S stem/Com onent/Deagce: Check all that apply) <br /> JZNon-Pressurized hr-Ground ❑Premmired In-Gmmd ❑ At-Grade ❑Mowe1>2A in.of suitable soil ❑ Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispcnal Compoaeat(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVl•reatoaent Arm Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 41- 7 (a - Gso 91. 70 <br /> VI.Tank Wo Capacity in Total #of ManufacturerGallow Gallons - Units $e pao y o <br /> New Trade fixutirg Tanks u V <br /> Septic or Bolding Tank 1000 /CBO / f/eR •,i �( <br /> Dozing Chamber <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Rhone Number <br /> 0(j.i-8s-/ 7/s-edi 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .�"774n //. -iF'-IU/ 6Slee— WrS�f893 <br /> VI Couin /De artment use Only <br /> Approved ❑Disapproved PermitFm Date Issued Issuing tgmluro <br /> g 3UU� 71,t 00 <br /> ❑Owner Given Reaeou for Denul <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> A#wh to complete plan for the system and submit N the County only on paper not ka than a as x Il inch&in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />