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eommeree.wi.gov Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 e <br /> is e o n s i n Madis n, WI 53707-716 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 532.205 <br /> Sr <br /> Sanitary Permit Application Stattee/'/brans/action umber ,`` <br /> In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate (�Ood ' IW U <br /> governmental unit is required prior to obtaining a sanitary permit. Now: Application forms for state-owned Project Address(if different than mailing address) --c <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> 1. Application Information-Please Print All Information �pg9$ Mf�tavn �rds� <br /> Property Owner's Name Parcel# 0/8 3327 02200 <br /> e e ) us S 07 9-/ -17 3-0oo-CVZCa*> <br /> Property Owner's Ma iling Address Property Location `/ , <br /> � - S 20$ •FG1624, <br /> City,State Zip Code Phone Number 5 <br /> e tS-t-e _j y fj 3 (circle one) <br /> H.Type of Building(check all that apply) Lot# T 37 N; R E o 4' <br /> ❑ 1 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 /> 'own of p/7 e e/J O <br /> III. Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A, ❑ New System IV-Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal Ll Permit Revision Ll Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) <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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> —30 o , S g 0 6 or) 45_0 <br /> VI. Tank Info Capacity inal #of Manufacturer <br /> Gallons GaTo llons Units <br /> New Tanks Existing Tanks Eco v 2 u <br /> a U <br /> Septic or HoWingYank <br /> ono 11060 <br /> Dosing Chamber 6 � 6--,;.d Az <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber's Signa lure MP/MPRS Number Business Phone Number <br /> i RJ-v_ RNrSA0/,,.-, `)/ <br /> Plumber's Address(Street , City,State,Zip Code) <br /> /3o x �5_1Y S/ - e N / � { s'yJ72 <br /> VIII. County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee �.r� Date Issued Issuing Age are <br /> El Owner Given Reason for Denial $ 3215/ / JTQ(llt 201 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> f�&%6C Is W1. Fzx* f5a464/c as d Glass .1 �l luve. /,2,4QKIL ,.20/a <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 inches in size <br /> SBD-6398(R. 02/09)Valid thru 02/11 <br />