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t:OfrlfDerct3.Wl.goy Safety and Buildings Division Countb <br /> a 201 W.Washington Ave.,P.O.Box 7162 hY ht <br /> t�len n sin Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> mp.rtmarrto<Commarce $ s <br /> Sanitary Permit Application Suite TransactionT <br /> o/Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 4-1 B <br /> unit is required prior to obtaining a sanitary permit Note: Application forms fm 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. 1 m,Stat. 3�7 [ )(/ <br /> L Application,Information-Please Print AN bhformation /- <br /> Property Owner's Name Parcel# <br /> J&rne.SGroue3 . 33.q(/S D/2 -42 29 -06.7oo <br /> Property Ownm's Mailing Address Property Location <br /> 3 875 ea 1?d Govt.Lot (;�' <br /> City,State Zip Code Phone Number Ys Y., Section 3 <br /> INC 6J i e-1l.✓� �g 3 T -'10 N; R /Scirc a one <br /> IL Type of Building(check all that apply) Lot# <br /> 1m 2 Family Dwelling-Number of Bedrooms [Ifs Subdivision Name <br /> Block# <br /> ❑Public/Commwcial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSMNwaer ❑Village of <br /> VII a I p Town of Jar Kaati <br /> Ill.Type of Permit: (Qheck only one box on line A. Complete line B if applicable) <br /> A ❑New Syne <br /> m RePlacem®t System Treatment/Ha ler�8Ti nkRehcemat OnlY. Other Modification to Exiatin System(e%Plain) <br /> B. D Permit Renewal ❑Permit Revuioa D Change of Plumbs O PermitTransfer to New List Previous PennitNumber said Date Issued <br /> Before Expiration owner <br /> IV.Tof POWTS System/Component/Device: Check all that apply) <br /> Nw-Pressurimd In <br /> -Goaund D Presnaized le-Gmuad D At-Grade D Mound>2A in of suitablesoil D Mound<24 i.of suitable soil <br /> D Holding Tank h0 Other Diepdsal Comp mcnt(exphm) rs rs4( ❑Pretreatment Device(explain) <br /> V.DispetrazIrrseartment Arm Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Disposal Area Requ¢ed(st) Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 *25.0 450. 0 98.` <br /> VI.Tank hdo Capacity in Total #of Manufacturer yy <br /> Gallons Gallons Unit y o <br /> New Tanks toreang Tanks <br /> y A W C7 F <br /> Septic or Holding Tank ` 'A t9 w.r 75o SKAt.J V <br /> rbmg Clmmher /7a. ..a( <br /> VIL RissponsibiBty Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print)) Plumber's Signature MP/NM Number Business Phone: <br /> // <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,L7760 X 3,f tve6sfrr ta+rf'Srfis7 <br /> wVIIL Court /De artment Use Only 42 <br /> It Approved D Disapproved �Jit ' Signature <br /> D Owner Given Reason for Denial S a(Perm / o7 <br /> Fee Date Issued las <br /> DL Conditions of Approval/Reas ans fm Disapproval <br /> Attach to complete plum far the system aid subeft to the Conray ody as paper not has Than 8 l sit lushes In size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />