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tI <br /> tpmmerce.wl.gov Safety and Buildings Division County I? <br /> 201 W.Washington Ave.,P.O.Box 7162 4 (A r n e <br /> seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled m by Co) <br /> artment of Comtn arcs 52 <br /> Sanitary Permit Application Stam Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Ls Atx✓ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forma for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. .Personal information you provide may be used for secondary <br /> purposes in accordance with the Priv. Law,s.15. 1 m,Stats. 2 X90 n <br /> L Application information—Please Print All Information <br /> Property Owner's Name Pm I# <br /> /Cert LO /t/Crn 03d - 9O,ts — DA&Io0 <br /> Property Owner's Mailing Address Property Location <br /> J.9 90 7 era N 6"-Y rr 414 f2a( Govt.Lot C}J <br /> City,SfamZip Code Phone Number yy., Section s <br /> QA Al to k P, -.5-M "3 , (cycle one ({`1 <br /> IL T of T Z1 N; R /f9 E or� <br /> Type Building(check all that apply) Lot# <br /> 9-1 or 2 Family Dwelling-Namber of Bedrooms Subdivision Name <br /> Block 31 a, SKS <br /> ❑Public/Commercial—Doacribe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> PrTowo of <br /> III.Type of Permit: (Check only one box an tine A. Complete tine B if appGmble) <br /> A_ ❑New System Replacement System ❑ Trammma/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous PamilNumber and Date Issued <br /> Befom Expiration Owner <br /> IV.Type of POWTS S stem/Consonent/Device: Check all that apply) <br /> 9 Nm-Pressurized In-Ground ❑Pressurized In-Cmound ❑ At-Grade ❑Mmnd>24 in mf suitable soil ❑Mound<24 is.£suitable soil <br /> O Holding Tank D Other Disposal Component(explain) ❑Preheatment Device(explain) <br /> V.D1s ersaVCreatment Arm Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 300 1 ly I I "13d 1 9d ti <br /> VL Tank Wo Capacity in TotaMa <br /> l #of nuficbrer $gs� <br /> Gallons Gallons Unita <br /> New Tads Fix ung Tanks 9 <br /> r� m y iL C7 i£ <br /> Septic or Holding Tads 800 200 / S/tea w <br /> Do"Chamber <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown.n the attached plana <br /> Plumber's Name(Print) Plumber's Signature MPMURS Number Business Phone Number <br /> R141'e I*.Gi n J / �� rdrSl 7/s- 06(o <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 76 O IV�w 3S W ks-. 74e zll� S`4893 <br /> VIIL Court /De artment Use Only <br /> Approved ❑Disapproved Permit Fee yj Dam Issued q Issuing AS rare <br /> ❑Owner Given Recon for Denial <br /> IX.Conditions of Apt roval/Reasom Cor Disapproval <br /> Attach to e.mpem p,m far Lha ayefe.and subna to the Cmmy.ay m Paper not len Imo a fax 11 lash,task. <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />