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commerce.wl.gov Safety and Buildings Division County [ <br /> 201 W.Washington Ave.,P.O.Box 7162 �t,f <br /> isconsin Madison,W1 53707-7162 Sanitary Permit Number(to befilled_mbyC..) <br /> Department of commerce 5-3Z,2,34 <br /> Sanitary Permit Application State Transaction Transsaaction qNumber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 1676 "/3 / <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) f fY <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary V <br /> purposes in accordance with the Privacy taw,s.15.04 1 m,Stats. L ) (:cPl✓�,� _ /K D <br /> t. Application Information-Please Print All Information <br /> Prope yOwn��er77's Name Parcel# <br /> &0 Ss./�uiJ �, o`]-D20-2-4o/b35-3-Ol-oDo-ouloo <br /> Property Owner's Mailing Address Property Location <br /> 7L C f G>d +�-GJ IC ! g/ r' A d Govt.Lot S/,, � 22 <br /> City,State �L Zip Code / Phone Number /vL y, y, Section J <br /> o e. G / / `fill ,�a 6 3 �� (circle one <br /> T N; R �6 Eo� <br /> H.Type of Building(check all that apply) � Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> D City of <br /> ❑State Owned-DescribeUse CSM Number ❑ Village of //.. <br /> F-Town Of._CrA. /4104 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable -o(30 2 _ _ — <br /> A' ANew System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only [I Other Modification to Existing System(explain) <br /> B. El Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> D Non-Pressurized fin-Ground D Pressurized In-Ground D At-Grade X Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevation <br /> D o asj ,jC2 c7 f ca/ 97 B� <br /> Vt.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u v <br /> New Tanks Existing Tanks p- <br /> aU o0 <br /> Septic or Hid' T k Y00() ` <br /> � i <br /> Dosing Chamber �w <br /> V <br /> Vll.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name Print) ,j Plumber's Signature MP/MPRS Number Business Phone Number <br /> 4/,A ��L �1 6N� jct�/f7 l/JtrG 2Z7e,9/ v7V,0'- 7-2,'&I <br /> Plumb,eprr's Address(Street,City,State,Zip Code) <br /> VII Coun /De artment Use Onl <br /> Approved D Disapproved Permit Fee ,}� QDate Issued p Issuing nt nature <br /> 3❑Owner Given Reason for Denial $ 56 / <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I x It inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />