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commerce.wl.gov Safety and Buildings Division County�7 <br /> a 201 W.Washington Ave.,P.O.Box 7162 914em <br /> I s Co n g i n Madison.WI 53707-7162 Sanitary Permit Number on be filled in by Co J <br /> Department of Commerce ,55) 2 3 / ( , <br /> Sanitary Permit Application State TransactionNumber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental ("Wi6v <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) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary /7tygo <br /> purposes in accordance with the Privacy Law,a.15.04(1)(m),Slats. ff <br /> I. Application Information-Please Print All Information /��e k'�✓y �//` <br /> Property Owner's Name Parcel# <br /> .S74OUe— (!IVh a� 0 -epa3 OJ/aoQ <br /> Property Owner's Mailing Address Property Location <br /> 4 6 Ste w S,Y4 Govt.Lot <br /> City,State Zip Code Phone Number y, % 7, Section /b <br /> rtS'f Cf �'� Sd43(, Lt// Sar i3trsl (eircleone <br /> T 4/ N; R /.� E o <br /> F <br /> IL Type of Building(check all that apply) Lot# <br /> AIor 2Family Dwelling-Number of Bedrooms dOO4 3 Subdivision Na me <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V, 9 f 6 r A Town of 3u,t JJ <br /> IIL Type of permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Or <br /> liy New System ❑Replacement System ❑Treatmenl/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ ChangeofPlumber ❑Permit Transferto New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> hV(.'f e o <br /> ,t"yf POWTS S stem/Com onent/Device: Check all tlaat a 1 <br /> Non-Preasurizedln-Ground ❑Pressurized In-Ground DAV-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank El Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> ersal/Treahnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 24 a 411 ("A) v3,( t, tea. tj <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v c o <br /> New Tanks Existing Tanks <br /> n <br /> C1;V yr � in W C7 fi. <br /> Septic or Holding Tank gQ d �Q / .S✓<l / <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print)/ Plumber's Signature 'L MP/MPRS Number Business Phone Number <br /> /12116/4 f/o k/4t <br /> Plumber's Address(Street,City,State,Zip Code) <br /> � 77(od w /N-eSsYsi t.�f� S tf8y3 <br /> VIIL Coun /De artment Use Ohl <br /> Approved ❑Disapproved Permit Feer Date Issued/ Issuing ignsture <br /> 11 Owner Given Reason for Denial S J .20 da s& AV) <br /> IX.COhdltinrr3 of Approval/Ressons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not leas than 8 in z 11 Inches in size <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />