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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 7(t///<1' <br /> scons i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> tAlospartment«cosommunce Seo z4 71 <br /> Sanitary Permit Application StawT t//ion Number <br /> In accordance with s.Comm.83 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental T. Ol&,d <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for slate-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 Privacy Law,s. 15. t m Stats. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> John / O d 11BD <br /> 3 8 7 07a� A-2 S6 /f 3fr-S osoo� <br /> Property Owner's Mailing Address Property Location <br /> —1A 7% Govt.Lot (C <br /> City,State Zip Code Phone Number ,t/ul , 2 9 <br /> / /., /., Section L <br /> a / ,�3 j 3 6/-2 3-99 /n a 6 rcle one <br /> II. ype of Building(check all that apply) Lot# E o <br /> (�l or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> Nr Town of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) — 713 _ _a <br /> A. kNew System ❑Replacement system y p y ❑Trea[mentMolding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Compo ent/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.Dis rsid/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 5�11) 6S— <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks v c v 2 _ <br /> V <br /> Septic or Holding Tank 0 <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa re MP/MPRs Number Business Phone Number <br /> �/ r <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Ise �6 ! / /f Cf/� _ —4,5g7l <br /> V111.County/Department Use Only <br /> JZ'Approved I ❑DisapprovedPermit Fee Date Issued Issuing at gnature <br /> $ � la <br /> El Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plain for the system and submit to the County only on paper not hes Wan a in x 11 inches in site <br /> SBD-6398(R.02/09) <br />