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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 u p- #(e_ <br /> i s co n s i n Madison,WI 53707-7162 Sanitary Pe"rimit Number(to be filled in by Co.) <br /> pepadm id of Commerce <br /> Sanitary Permit Application State Tm/rt�s�t ion Num( r <br /> In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate L��t'E IP.Ule <br /> governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-awned Project Address(if different than mailing address) <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may used for <br /> secondary purposes in accordance with the Privacy Law,s. 15. 1 (m),Suits. <br /> I. Application Information-Please a 7901? <br /> Pro7oZ Owner's Name o t_11 Parcel# <br /> 1 \ E 0QI-QIt �r Q <br /> Property Owner's Mailing Address Property Location <br /> S w Gov[.Lot I <br /> Ciry,State Zip Code Phone Number _''A, '6, Section <br /> 6)r�1k0 702o I T y0 N: R �s (circle <br /> Eo or <br /> II.Type of Building(check all that apply) Lot# <br /> Ej <br /> R1 1 or 2 Family Dwelling-Number of Bedrooms _ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of T G .$'O I✓ <br /> M.Type of Permit: (Check only one box on line A. Complete Bne B if applicable) <br /> A' 8 New System ❑ Replacement System y ep y ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. 11 Permit Rrncwal El Permit Revision <br /> ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a 1 ) <br /> B Non-Pressurized Inllrwnd ❑ Pressurtzed In-Ground ❑ At-Gmde ❑ Mound > 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Prea-mo hent Device(explain) <br /> V.Dispersndi r Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> r9 0 S 7 O <br /> VI.Tank Info Capactty in Total #of Manufacturer <br /> Gallons Gallons Units a 2 U <br /> New Tanks Existing Tanks u <br /> o m <br /> t' Holding Tank (� O C) 1 14 cc 'c e, v <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned, respontib for installation of a POWTS shown on the attached plans. <br /> Plumber's Name('Print) Plumber' ignamre MP/MPRS Number Business Ph a Number <br /> 1✓ac.� T w, �s !f ,26335 7/J �3�-.� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 70 9 l V54 Sire (- S4 r o (.f/ <br /> V%.County/Deparlinent Use Only <br /> Approved ❑ Disapproved Permit Fee s�pp Dane issued Issui Age `ignamre <br /> ❑ Owcer Given Reason for Denial d5 3 2p <br /> IX.Conditions of Approval/Reasous for Disapproval <br /> Attach to complete plans for We system and submit to the County only on paper not less than 8 in x 11 Inches in size <br /> SBD-6398(R.02/09)Valid than 02/11 <br />