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CORlfll@fC@.Wl.goV Safety and Buildings Division Col <br /> 201 W.Washington Ave.,P.O.Box 7162 r~✓ f' <br /> tiieonsin Madisoq WI 53707-7162 SanitaryP 't Numbs(m be£died in by Co.) <br /> rtrsrent of Cemmeroa 4 s z2— <br /> Sanitary Permit Application State Tramac ion Number <br /> In accordance with e.Comm.83.21(2),Wis.Adm.Code,submission of this form re the appropriate govemmenW 402.7 <br /> .33 <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Add s(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be rood for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1 m),Stats. / <br /> 1. Application,Infotmatfon—Pkax Print AN Information .7 fg f e r 77— W4. s e <br /> Property Owner's Name ,� parcel M <br /> Lirewoetr �AoM — iQir" MCr.e✓ 5� 03 —s3,4 jr— O'l MO(l <br /> Property Owner's Mailing Address Property 'on <br /> P.aa.X 649 GavLLot <br /> City,State Zip Code Phone Number <br /> sc �s E yy Satan a8 <br /> Ae .S48J7 (circle one) <br /> IL Type of Building(check all that apply) Lot g T 1,; R /6- E o� <br /> ❑ 1 or 2 Family Dwelling—Number of Bedrooms I Subdivision N me <br /> Block R <br /> IN m <br /> PubliclCra acial—Describe Use RA rl It <br /> ❑ City of <br /> ❑State Owned—Desrn'be Use CSM <br /> Number <br /> 1 n ❑Village of <br /> a v' I Town of 1s� <br /> III Type of Permit: (Check only one box on Hine A. Complete tine B if appliable) 1 <br /> A. Z New System ❑ lacement S tem ❑Trmtmeot/Hold' <br /> ye Rap Ya mg Tank Replacement only ❑Other M rcation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous I wood Numbs and late Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S to a/Com onent/Device: Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑Pressurized br-Ground ❑ At-Grade ❑Mound>24i.of suitable sod ❑ Mound< in,ofsuimble sail <br /> ❑Holdimg Tank ❑Otha Dispersal Component(explain) ❑Prdmtmcnt Dcvice(exptain) <br /> V.DispersaVfreatiincnt Area lnformatim: <br /> Design Flow(gpd) Design Soil Application Rme(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> d A .S S 76 /®eo 1 9'3. T <br /> VL Tank Wo Capacity in Total a of Manafacnuer <br /> Gallons Galleon Units $R <br /> New Talo Eastug Tanks <br /> y <br /> Septic or Holding Tank g�0 foe z s/G w s✓ <br /> Daring Clamber <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POINTS shown er the an, hal plana. <br /> Plumber's Name(Print) Plumber's Signature Mp/MPRS Number Bus Phone Number <br /> a/c ffv k�m s / 1iz ls8s / acs X66- fir 7 <br /> Plumber's Address(Sheet,City,State,Zip Cade) <br /> o{ 7764 /5� -7-sr— <br /> V% <br /> 7.fVII Corm /De artment Use Only <br /> "TCApproved ❑Disapproved Permit Fee Dam Issued _7 Issmmg rg amre <br /> ❑Owner Given Reason for Denial U I <br /> IX.Candidness of Approval/Reass nv for Disapproval <br /> Attach as cosptete ptamefer the rysies and subwa b the County only m paper stat ks ease 8 to all haps size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />