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eommeree.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 a//`A-1 e <br /> iseonsin Madison,WI 53707-7162 SaniaryPermitNumber(tobefilled inbyCo.) <br /> Dapartment of Commerce 5-52 /3 -7 <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 govemmental 1('�GQ/b SJ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(ifdifferent 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 1 m,Stats. C��.U� SI__J 1 7b <br /> I. Application Information-Please Print All Information Y"r'I/ <br /> Property Owner's Name Parcel# r�Ofl-1cF/.2'0$/00 <br /> yo e-5 +wJ�/'Sc7'tf :ll �� � 0-7-06-2-2-8-17-19-505-001-0/1000 <br /> Prope wner's Mailing Address 1 Property Location <br /> 311'O/ 191--It* /V Govt.Lot / <br /> City,State Zip Code Phone Number <br /> tvC 0 L)2 � '/., /., Section <br /> /Y/ ve) 53',3,0 '63- 7s3 392 77pp� cncle one <br /> T��N; REotI V <br /> 11.Type of Building(check all that apply) � Lot# <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> / ❑ City of <br /> ❑ CSM Number El VillageofOwned-Describe Use 7h <br /> own of. <br /> III. <br /> Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ' P6w System ❑ Replacement System ❑Treatment/Holding Tank Replacement <br /> ent OnlY Other Modification to Existing System(explain) <br /> ) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade 0-Mound2:24 in.ofsuitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdst) Dispersal Area Required(sO Dispersal Area Proposed(IJ) System Elevation <br /> SO / ASO f 41S0 9 ,$ <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> 9 <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber /o o <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum/ber's Signature MP/MPRS Number Business Phone Number <br /> / <br /> .(t�lTr�'e. GI)�VU//21 GV Qe� Zz76 Cf/ r7 9-7�-0 b <br /> Plumber's Address(Street,City,State,Zip Code) <br /> A! S% 5-i / evJ 6,1_F S Fl72 <br /> VII <br /> "Conn <br /> /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee <br /> Date Issued Issuing Agent Si to <br /> ❑Owner Given Reason for Denial $ 57 v `^�'L �9 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> s riLle „ 00¢ a C F7001- Prat:l, s« 5-�v4y a tiC&-+ ala <br /> Attach to complete pians for the system and submit to the County only on paper not less than 8 urs x 11 inches in size <br /> SBD-6398(R.02/09)Valid third 02/11 <br />