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commereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> iseo n s i n Madison.WI 53707-7162 Sani eary Perri Number(lo be filled in by Co) <br /> Oepartmerrt of Commerce 83 <br /> Sanitary Permit Application State Tramacti .Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental ­01— <br /> unit is required prior to obtaining a sanitary permit. Note: Application fortes for slate-owned POWTS are Project Addres (if different thin mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> ees in accordance with the PrivacyLaw,s.15.04(1)(m),Stan. <br /> I. A BcationInformation—PleasePrintAlllnformation <br /> Property Owner's Name Parcel q <br /> ! .i <br /> ��k Tory►AsZecJ 5 aloa 6- 33 el A) <br /> ProperlylOwnernc Mailing Address 0 t� Property Location <br /> 7' I/ u rte( Z-1 - �(� Govj. <br /> Lot <br /> City,State Zip Code Phone Number •�,/�J �j JJ L. �� <br /> ii of G� r `/83a 6SO / 7 J /VF <br /> '36d., Section <br /> ffcic one" <br /> IL T of Building check all that a 1 - Lel s 'f_�_N; R. E or <br /> � <br /> Type g( PP y) <br /> At or 2 Family Dwelling-Number of Bedrooms_ Subdivision Na e <br /> Block s <br /> ❑Public/Commercial-Describe Use <br /> -'-' — ❑City of <br /> ❑ CSM Number Stale Owned-Describe Use ❑ Village of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System Y ep y ❑ Treatmrnl/Hokling Tank Replacement Only ❑ Other Modifi ton to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Parmit Revision ❑ Change Plumber List Previous it umber and Date nIssued <br /> g ❑Permit Transfer to New -I U <br /> Before Expiration Owner <br /> yyI��V..��T a of POWTS S stem/Com oment/Device: Check all that apply) <br /> ;5'Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ Al-Grade ❑ Mound>24 in.of suitable soil in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain)___ _. _ ❑prcocalment Device(explain) _ ___ <br /> V.Dis ersaLTreatment Area Information: <br /> Desi Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ��0 K 7 �i Fl O 9� <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units e V $ o <br /> New Tanks Existing Tanks <br /> 3 8 a o a <br /> Septic or Ilo� O l) �� �/ <br /> Dosing Chamber V O'�o <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POINTS shown on the attact ed plans. <br /> Plumber's Name(Prim Plumber's Signature Bn MP/MFRS Number Business Phone Number <br /> Sam GJj"27 z z7G9/ 3Yq-7�f � <br /> Plumber's Address(Street,City,State.Zip Code) <br /> 6,;r Shy e, s�/r7 <br /> VIILCoun /De artment Use Onl <br /> ❑ Approved ❑ Disapproved Permit Fee Date Issued Issu gent Signature <br /> ❑ Owner Given Reason for Denial S ��� ((J�k) 07 <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> T ll' qboa <br /> Attach to coopkte plan for the ayatrm aM wbmit lathe County oNy on paper mt ks than 8 fa x 11 Irchea N lu <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />