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4000, commefee.Wl.gov Safety and Buildings Division County <br /> 201 W.WasWngton Ave.,P.O.Box 7162 8"e A f Y' <br /> i sen n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ..pa.n,ra,n of ComnlwMe 3 2 <br /> Sanitary Permit Application SaeTransaction Number <br /> In accordance with e.Comm.83.21(2),Wu.Adm Cada,submission of this'foor to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application;fomes for state-owned POWTS are Prgem Address(if different than reading address) <br /> submitted to the Department of Commerce. Penioml information you provide my be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1 m),Stats. �h r] <br /> L Application Ldormation-Please Print All Information R f BSlk E Yd//owe h-1 Rd• <br /> Property Owner's Name Parcel# <br /> JAM CJ I3rakAat5fra«t 00w - 9/3S - DyyOCJ <br /> Property Owner's Mailing Address Property Location <br /> 3.AX0 LEXrrr fsn f7ve Govt Lot <br /> City,State Zip Code Pone Number ( � <br /> Yh Yh Section 7 w <br /> .1'!1006 11,-ew Al,/y) SS/1G Gsl ,90- ledy T 4149 N; R (evcE�) <br /> IL Type of Building(dteck all Mat apply) Lot# / (9 <br /> m �j <br /> 0 1 or 2 Family Dwelling-Number ofBedroos -f Subdivision Name <br /> Block# <br /> ❑PubadCommercial-Desmibe Use <br /> ❑City of <br /> ❑Slate Owned-Describe Use CSM Number ❑Village of <br /> Town of t7r4 k f1'w <br /> IIL Type of Permit: (Check only one boa on lime A. Complete 6e B if applinbk) <br /> A New system ❑ <br /> y1' Replacement System ❑Treaonenf/Hdlding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permd Tramfer to New List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV. a ofPOWTS S tem/Com one VD Av. Check all tha w <br /> 14 Nrn-Pressurized in-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 ire of savable soil ❑Mound<24 in.ofsuitable soil <br /> ❑Holding Tank ❑OtherDispersal Ccmponmt(explzm) ❑Prareatmrnt Dovice(explain) <br /> V.DispeirssVl'resunont Area Informations: <br /> Deaigm Flow(gpd) Design Soil Application Rate( Du ereal ea <br /> G S G 7 P A¢ Requned(st) Dispersal Area Proposed(at) System Elevation <br /> W. 9�r <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallon Gallon Units x°t, o.g o <br /> New inks Axistirrg Treks �j U b S <br /> Septic a Holding Talk T*N S-O <br /> Dosis Chamber <br /> VII.R possgbffity Statement-t,the undersigned,assume responsibility for installation ofthe POYM shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/tv1PRS Number Business Phone Number <br /> R/cic AXV A r1' .4pa.elw.e� e� -esu 7rr-- 86` ;4 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 177ggrO H wc6s><r avr;sy eq_7 <br /> VII Conn /De arknent Use Only <br /> Approved 1 ❑Disapproved Perred Fee Datelssued Issuing Signature <br /> ❑Owner Gis�50 if�l 7 <br /> vrn Rwon for Denial � <br /> IX.Conditions of Approval/Reasore for Disapproval <br /> Aaaeh to eoapkte plawfor the syoleaaad suhah the Cauoty aadym pyar retlea[Wwarrs sll hwhn melze <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />