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�'scocommereeml.gov Safety and Buildings Division County <br /> //�� <br /> „ 201 W.Washington Ave.,P.O.Box 7162 .^n IT <br /> / . ue <br /> s'n Madison,WI 53707-7162 Sanitary Permit Number(to be fdled n by Co.) <br /> Departmend of Commerce Sz 1 ®o <br /> Sanitary Permit Application Sate Transaction Number <br /> In accordance with a.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 Note: Application forme for sateowned POWTS we Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be wed for secondary e <br /> purposes in accordance with the Priv Law,s.15. 1 m State. $$33 a/bL/e Brit O�' Rp, <br /> I. Application Information-Please Print AN Information <br /> Property Owner's Namev parcel# <br /> .g ,n/ *nAt-he olb 34x3 o/ s-ao <br /> Property Own"'a Mailing Address properly Location <br /> /tf 6 / /Y7A SY• se>rm 4,4 6i- <br /> City,Sas Zip Code phone Number Yy a W '/y Section .13 <br /> Wasaca 1"N Sb o43 5-67-933- 7.1/7 (circle one <br /> Posy) <br /> IL Type of Building(check all that a Lot# T 39 N; R_J 7 <br /> 1 fZi or 2Family Dwelling-Number of Bedroom Subdivision Name <br /> Bloch# <br /> ❑Public/Ccennum pal-Describe Use ❑City of <br /> ❑State Oaned-Describe Use CSMNumb" 37,el,1Z ❑Village of <br /> w 206 25/ QTown of 1"440111 <br /> IIl.Type of Permit: (Check only one box on Ibne A. Complete tine B if■"Ibcabie) <br /> A. 19 New System ❑Replacement System ❑Trea ummHoldiag TankRepl..t Onty ❑Other Modification to Existing System(explain) <br /> B. ❑permit Roneweh [I Permit Revision ❑Change oFPlumb" ❑Permit Tramf"m New <br /> L stPrevimu PemritNumber and Dab issued <br /> Before Expiration Own" <br /> IV.Type of POWYS S shem/Can en/Device: Check A tlut apply) <br /> gNon-Prmaurinad In-Ground ❑Premurvcd In-Ground ❑At-Gmde ❑Moumd>24 in of enablesoil ❑Mound c 24 in.of auiublesoil <br /> ❑Holding Talc ❑0th"Dwinasal Component(explain) ❑Pratrmatmmt Devin(explain) <br /> V.Dispersolfrincistmesit Area Information: <br /> Design Flow(gpd) Design Soil Application RaWgpdsf) Disposal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 360 1 . -4,- 1 Gdd 1 Edo 43, o <br /> V1.Tank Info Capacity in Total #of Mamrfacbu g <br /> Gallon Gallons, Unix fi R o <br /> New Tama EaWmg Tanks � F3 nr <br /> 9 � b� <br /> w . y iz 0 i% <br /> Septic or Holding TankO0 �00 / .f.L!p(ori )- <br /> DorhgCbwber <br /> VII Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached pians. <br /> Plumber's Name(Print) '/ Plum^b�es's Signature WaVRS Number Rasumas Phone Number <br /> Ire,G le ?O lei n ,3 � cE� ��S-tfS'/ 7/S. Sb b-t-/�S`7 <br /> Plumber's Add—(Sant,City,Sate,Zip Code) <br /> -77 f,, . <br /> VEL Cam /De artment an Od <br /> Approved ❑Disapproved Permit Fn ,D/ab issued Imnmg ignture <br /> ❑ wn" <br /> OGivnReaemforDmial g AIN I�22WD <br /> IX.Conditions of ApprwaUReasan for Disapproval <br /> AWch a coaapkh phrnfer the system and sub"lathe Canty only ass paper not les than 8 W x 11 inches 6 dere <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />