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commercemi.gov Safety and Buildings Division County n �/ <br /> 201 W.Washington Ave.,P.O.Box 7162 („) .N n 4 bl <br /> tilisconsin Madison,WI 53707-7162 Sanitary Permit Number(tn be filled in by Co.) <br /> epartmmm <br /> ent of Coerce 5 // 2 3 (o /7 <br /> Sanitary Permit Application State Transaction Number <br /> N 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 <br /> Now: Application forms for state-owned POWTS are Project Address(if different 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,a.15.04(1)m,Stats. tUJ <br /> L A licadon wormation-Please Print All Information_ O 7 O E• CoAA e.•a L/< l?d (� <br /> Property Owner's Name Parcel s 0 <br /> WA ;+<e& fa. C�. 3 oar N5- <br /> Property Owner's Mailing Address -. Property Location <br /> // & 3( T" fi Sf• v Govt Lot 3 <br /> City,State Zip Code Phone Number Section .76 <br /> {'�rnaes r/U ^v SSY33 bfl- ySN- ,1465 (circle one) <br /> �(L <br /> IL Type of Badding(dtedt all that apply) Lott! T_YON; RE or® <br /> 191 or 2 Family Dwelling-NumberofBedrooms // /Sr. ddivviisiioln Na/me <br /> BlockN <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑� Village of <br /> p(l Town of Okk/A At? <br /> Ill.Type of Permit: (Check only one boa on line A. Complete tine B if applicable) <br /> A. ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> H. ❑Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber ❑Pe milTransferto New List Previous Permit Number and Date Issued <br /> Befine Expiration Owner <br /> IV.Type of POWTS S stem/Com mt(Device: Check all that apply) <br /> ❑Nw-Preuurized In-Ground ❑Pressurized hr-Crmmd ❑At-Grade ❑Mound>24 in.of suitable soil N Mound<7n,in,of suitable soil <br /> ❑Holding Tank ❑Other Dspersal Component(explain) ❑Prnrcatmcnt Device(explain) <br /> V.DispersaV17matruent Aria Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 4.50 `J l/.S-O Soy97, 6 7 <br /> VL Tank Info Capscity in Ton A of Manufacturer yy <br /> Gallon Gallon Units <br /> New Tanks Eszm g Tanks H sup u 7 <br /> Septic er Holdug Tank /B p 0 /see <br /> Dosing Cbav6ef G D o 1 1booIN <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature W/MPRS Number Business Phose Number <br /> /P-"e- /11/0,0/eina /?tee [.►.4 !f/.�r�a—: dds8s� y/s >�6 G — 5is�7 <br /> Plumber's Address(Strce City,State,Zip Code) <br /> .���6D H�- 3.r we.dsrt, ,. wr Sy893 <br /> VIIL Conn /De armtent Use Only <br /> Approved ❑Disapproved Permit I= Date Isssnuped Issuing Signature <br /> ❑Owmer Given Reason for Denial S 3 /J �rt. (l/tt,lL <br /> IY.Conditions of Approvsl/Reasau for Disapproval <br /> Attach to complete plan for the ryOem and submit to the Cos dy only on paper not len than 812 x 11 inches in rim <br /> SBD-6398(R.01/07)Valid this 01/09 <br />