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commerceml.gov Safety and Buildings Division County <br /> n 201 W.Washington Ave.,P.O.Box 7162 ;�t <br /> se o n s i n Madison,W1 53707--7162 Sanitary Permit Number(to be filled in by Co.) <br /> tiDeparftneint of Commerce 53,Z 2 3 <br /> Sanitary Permit Application State Transaction Number <br /> in accordance with s.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 forms for state-owned POWTS are Project Address(if different than mailing address) j <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04 I m,Stats. <br /> 1. Application Information-Please Print All Information <br /> Prope y Owner's Name Parcel# <br /> S a, 0-olo-2 4a/b 3s 3 or 000-ol�l o 0 <br /> Property Owner's Mailing Address Property Location se-i^tit"Z <br /> 7L C ircv e C/ le! 6/ re Govt.Lot 3 <br /> City,State / Zip Code Phone Number AZ y., 560 y., Section <br /> // �Qcircle one <br /> � G T N; R E o� <br /> ll.Type of Building(check all that apply) `2 Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑ Block# <br /> Public/Commercial-Describe Use .._ <br /> ` <br /> ❑City of <br /> ❑State Owned-Describe Use [:7umber ❑Village of <br /> Town of C A,41A9 silt <br /> ill.Type of Permit: (Check only one box on line A. Complete line B it applicable <br /> A' ANew System ❑ Replacement System g Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> y p y ❑Treatment/Holding <br /> B• ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade X Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersat/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> Vt.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units � t? v <br /> New Tanks Existing Tanks <br /> o S <br /> a U y ti rn <br /> Septic or HgldM&lAnk <br /> Dosing Chamber <br /> v <br /> VI1.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Na nte Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> � 71 /t�y1:!W47 1li✓ram.- 2 2.76/9/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> V111keCounty/De artment Use Only <br /> Permit Fee Date Issued Issuing t nature <br /> Approved ❑Disapproved ,/� 4 ,/ Q <br /> ❑Owner Given Reason for Denial S 375! / <br /> IX.Conditions of Approva[/Reasons for Disapproval <br /> fe,n,',,L- Se, <br /> Attack to complete plans for the system and submit to the County only on paper not less than g 1/2 x 11 inches In site <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />