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1� S i <br /> eommerce.wi.gov Safety and Buildings Division VCounty <br /> 201 W. Washington Ave.,P.O.Box 7162 r ry e:741'isconsin Madison,Wl 53707-7162 Sanitary Permit Number(to be li Iled in by Co.) <br /> tDepartment of Commerce 5,32 ) 34 <br /> Sanitary Permit Application S[at/eT/a�nsac/tionN�mbcr — 19 <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental / !f/nuWtaN/l \�/ <br /> unit is required prior to obtaining a sanitary permit. Noir Application forts for state-owned POWfS are Ill eject Address(ifdifferenl than'mma-illiin`address) <br /> submitted to the Department of Commerce. Personal inlbnnation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. O 0 <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# (� 1 <br /> Prop rty Owner's Mailing Address / Property Location PL/ <br /> // "RIT, «,�`ia� ��� Govt.Lot_ <br /> City,Slate Zip Code Phone Number / <br /> 2 e� '/., Section <br /> Jz-7— / cn'cle on` <br /> 11.Type of Building(check all that apply) Lot# <br /> 0-1__2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> CSM Number 11 Village of <br /> [J State Owned-Describe Use <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) - - - - - <br /> A' .5y'- ❑ I reatmeno11o1din b y (explain) <br /> ❑ New System 3meeplacement System g Tank Replacement Only Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of 1'lumbcr ❑I'crmit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type cf POWTS S stem/Con onent/Device: Check all <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.ut suitable soil ❑ Mound<24 in.ofsuitable soil <br /> "olding Tank ❑Other Dispersal Component(explain) _ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sl) System Elevation <br /> O <br /> VI.Tank Info Capacity in 'otal #of Manul'actm'er <br /> Gallons Gallons UnitsO 9 <br /> V - h <br /> Ncw Tanks F.xisling <br /> c. U <br /> Sepiiaor Holding Tank <br /> Dosing Chamber <br /> VI 1.Responsibility Statement- 1,the undersigned,assume responsibility for Installation of the POW'PS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature MP PIIS Number Business Phone Number <br /> Ze) -e �/ r-5,4.,/rr 2 z 16 g <br /> Plumber's Address(Street,City,State,Zip Code) <br /> AL5X _T/V S ii'e- j /•J S`/� 72 <br /> Vlll.Coun[v/De artment Use Only <br /> ,�,/ Petro F' c Date Issued Issuing A` ignalure <br /> Jd Approved ❑ Disapprove)❑ Owner Given Reason for Denial S 375 3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete Plans for the spalem and submit lu Ibe Cunnly Pah'en Paper not less man g 1/E x 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />