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eommerce.wl.gov Safety and Buildings Division County <br /> 201 W. Wio;mngton Ave., P.O. Box 7162 4 N <br /> fi seo n s i n Madison, W 153707-7152 Sanitary Permit Number(to be filled in by Co ) <br /> Department of Commerce 4 / 8 T n <br /> Sanitary Permit Application State lranaa"i "amber <br /> In accordance w nh s Comin. 83.21121.W Is. Adm Code,submisvon of this form to the appropriate governmental �- <br /> unit is required prior to obtmnmg u sanuan permit Note. Application Binns for stale-owned POWTS are Project Address(if dtfTerem than mailing address) <br /> suhmmed m the Department of C"Innuc ce. Personal inkainabon you provide may be used for secondary <br /> u uses In accordance with the Privacy Law,s. 15.04(1 am),Stats. <br /> I. A lication Information-Please Print All Information <br /> Propem Orrner-sName Parcel#07_ °j3--.a-_yl-16-Sit-$ <br /> Sfew I I W003 os-oma -DI oco <br /> Propem Ostner s Matbne Address ^� Properly Local n 03� Com/ / _ Da- <br /> I 0 r r I e .V V. Govt Lot -"U�"f <br /> Crn_Smte Zip Code Phone NumberA,y,, _ � y,, Section 31 <br /> S+f71L,)AQ VO V-% 6s� �J - 1'y�N. H��_IEon .. <br /> H. Type of Building(check all that apply) Lot a <br /> Subdivision No me <br /> (� I or 2 Famd) Dwelling-Number of BedrooiIts <br /> Block a <br /> ❑ PabIlc:Commerclal-Describe Use — ❑ City of <br /> ('SM Number ❑ Village of <br /> ❑ Sime Owned- Dcxnbe UseLi IS S <br /> VI P f"town o _ <br /> 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ' A ❑ Nee tis stem Replacement System ❑ 'i'reatmenl/Ioldinglank RePlacement OnlY Other Modilcation to Ixlsting System(explain) <br /> List Previous I e-mit Number and Date Issued <br /> B. E, Penna Renewal ❑ Permit Revis iun ❑ Change of Plumber ❑Permit'17ans ter to New <br /> Before Expuauon Owner <br /> IS. Type of POWTS Svstem/Cum onen t/Device: (Check all that apply) <br /> �p Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>_24 inofsudable soil ❑ Mound< 4 inofs'unable sod <br /> ❑ Holdlne Tank ❑Other Dispersal Component(esplatn) ❑Pretreatment Device(explain) <br /> \'. Ds ersa Vfreatment Area Information: <br /> [ksnin Flow (gpd) Design Soil Application RawigpdsO Dispersal Area Required(sf) Dispersal AreaProposed(st) System Elevation <br /> SD o , 7 41 so <br /> V'1.Tank Info Capacity to 'lural a of Manufacturer - <br /> 0 0 <br /> i Gallons Gallons Units <br /> New Tanks liuks E p <br /> 'epuc r lloldm2 l;utk x^fV w I e,w r 1G <br /> \ 11. Res ponsibilipStatement- 1,the undersigned,assume responsibility for installation of the POW I'S shown on the at ched plans. 1 <br /> I'lumbtt4 Name(Poco) Plotter's Signatu c MP/MPR.4 Numbe Business Phone Number <br /> �e'S p�Y l��a 2,2S � 7/� �6— pv�� <br /> Plumbers Address(Sneer City.Slate,Lip Code) r <br /> LIw �� e Sir f SSS 3 <br /> I' <br /> S. 111j, Count /De artmem Use Only <br /> FS <br /> D'nle Issued Issuing Age alure <br /> Approted Dlsappruved <br /> Owner Given Reason Ihr Denial /6�aY r67 <br /> IV Conditions of Approval/Reasons for Disapproval <br /> mach m complete Mans fur the ryvvm and wannit no the('uunry load}on paper nor dtsa then M ui a 11 Inch sin ear <br />