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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> i s c o n s i n Madison,WI 5 3 707-7 1 62 Sanitary Permit Numbe to be filled in by Co.) <br /> Department of Commerce b <br /> Sanitary Permit Application State Transacilumber ( r <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmentalaq <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 1 m,Stats.I. Application Information-Please Print All Information O o7 t V 1n/, C0o Floors // -, p <br /> Property Owner's Name Parcel# -��- <br /> Lan ,:�i 1JL'Q 3-5- -b - o0 <br /> Propertywner's Mailing Address Property Location <br /> C1-RO Vl C r�o Keck 1 � ° Govt.Lot mac_ <br /> Citv.State / Zip Code Phone Number ���_y Section }- <br /> '• / �1 L� (circle on <br /> l TN; R1E . <br /> 11.Type of Buildin ( heck all that apply) Lot# I <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V'3 3 1• '-,vu own of ()lJ IL <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System <br /> y El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. Permit Renewal ❑ Permit Revision ElChange of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Befo a Expiration Owner -5 3 0��o -I <br /> IV.Type of POWTS System/Component/Device: Check all that a 1 <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 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 ersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 1 ,s 3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 4 c <br /> New Tanks Existing Tanks w i " n <br /> c B <br /> aU Z h 'A wC7 a <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl er's Name Print Plumber' Sign MP/MPRS Number Business Phone Number <br /> \up 0 %,l YYA I as I <br /> Plumber's Address(Street, ity,State,Zip Code) JV <br /> f en 6491c), <br /> _VUI.County/Department Use Only <br /> pproved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> $❑Owner Given Reason for Denial �' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R.02/09) <br />