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+- r• <br /> Gammerce.wi.gov <br /> SCO s' <br /> Safety and Buildings Division Count <br /> 201 W.Washington Ave..P.O.Box 7162 rntotL— <br /> Madison, <br /> WI 53707-7162 Sanitary I ermtt Number(to be filled in by Co.) <br /> Department of Commerce . J 16t <br /> Sanitary Permit Application StaleTransactt°"gum r I , <br /> In accordance with s.Comm.S3.2I(2),Wis.Adm.Code,submission of this form to the appropriate governmental 1 t-13-- .3- 7 l[jl� <br /> unit is required prior to obtaining a sanitary permit, Note: Application forms for state-owned POWTS arc Project Address(if different than mailing address) V 1 <br /> submitted to the Deparurnnt 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. C�spr ok pr. <br /> I. Application Information-('lease Print All Information � <br /> Pt° cityOwner's tiamC (6.4354 Pareel p 034.(���-p,7�itK t P e, man P7-01- -37-1S-1 -4-0/.- -01teC <br /> Property Owner's <br /> Ownerr's Mailing Address Property Location <br /> 1 -1 q 5' - i., Go t.Lot <br /> Cit State -Zip Code Phone Somber ��� , i <br /> J �_ .�} fr (� :/., /., Section <br /> �f -la:fit J rl E I`-'q V 1Is-q `J- C? 1.37 ` R yl(circlf°net, <br /> II Type of Building(choek all that apply) I.ot+ - !Z3 <br /> or 2 Family I)wclling-Number of ltedrooms Subdivision Name <br /> Block a <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> CI State Owned-Describe Use_ CSM Number ❑Village of_ <br /> Towitof�fc-.4('N. LD fee,. <br /> 1 • <br /> Ill.'(Type of Permit: (Check only one lox on line A. Complete line B if applicable) <br /> 0 New System 0 Replacement System 0 Treatmenvllolding'rank Replacement Only 0 Other Modification to Existing System(explain) <br /> • Li <br /> Lst Previous Permit Number and Dale Issued <br /> B. Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑I'ertnit Transfer to New J rr 1r <br /> ie' re Expiration Owner 32�t�a.. Z-3I - f <br /> 1V.Type of POWFS System/Component/Device: (Check all that apply) ' <br /> ❑Non-Pressurized In-Grotnd ❑ Pressurised In•Ground ❑At-ciradc ❑ Mound 7 24 in.of suitable soil Astound<24 in.of suitable soil <br /> ❑ I t°lding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersalPl'reatment Area Information: <br /> Design Plow(gpd) Design Soil Application Katc(g}xisl) Dispersal Area Required(s1 Dispersal Arca Proposed(at) System Elevation <br /> 3oe / Soo Son 9g•17 <br /> VI.Tank Info i Capacity in Total a of Manufacturer <br /> Gallons Gallons Units ^` l2 <br /> New Tanks Existing Tanks ti .' v Yi <br /> Septic or llolding Tank is-D <br /> -75-70 1 e Li X Dosing Chamber SCSD r; `J ��'LJ i <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility tier installation of the PO%VTS shown on the attached plans. <br /> Plumber's Name int) r Plumber' Signature ` MPIMPRS Number Business Phone Number <br /> \164t? 1i-x'101 In i'--7L-'g l -715 3tM--ia 2( <br /> Plumber a Address(Street,City.State.Zip Code) <br /> Pa 514 ,57 re/r) 1 S-(ST <br /> V 11.County/Departntent Use Only <br /> Approved ❑ Disapproved Permit Fee Date l�sjsueii lssuin gent Signature �� - <br /> II\\ <br /> 0 Owner Given Reason for!)coda! S D S" 1 1 y(k%�� I n t e.,--) <br /> IX.Conditions of Approval/Reasons fur Disapproval <br /> Pe(ill ri en{ lleCt° Sx?ifires g---3)- 13 <br /> Altach to complete plans for the system and submit to the County ugly on paper not less than 8 1r2 s 11 inches in size <br /> SBD-6398(R.02109) <br />