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COmmerCem.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 p u M n'C <br /> tiDepartnimit isconsin Madison,Wl 53707-7162 Sanitary Permit Number(to be filled m by Co.) <br /> mof Commerce 5404560 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental �r7 k6G) <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are ProjectAdd'. (if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary ea"*� Xao( V <br /> purposes in accordance with the PrivacyLaw,s.15.0 1)(m),Stats. Ll"�r ' / <br /> I. A tication Information-Please Print AB Information 7549 (atrac. V 2,r 13 BX 12) <br /> Property Owner's Name Parcel#p}O�.d-dr�O• 'S <br /> Dar✓--e// ZIP nil ells 'Tr � I5- 93a-ogToOC' (Ar/vi713) <br /> Property Owner's Mailing Address Property Location <br /> 75-y 9 G o /Zd. U• Govt.Lot <br /> City,,State Y Zip Code Phone Number Yy Y., Section of <br /> DA n 6 rY J-if e7 D (circle one) <br /> IL Type of Building(check all that aPP1Y) Lot# 1 _ <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block yt11a aF a 1!W lake <br /> ❑Pubhc/Commercial-Describe Use /Z <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number El Village of <br /> Town of IG fA s'a <br /> IIL Type of Permit: (Check <br /> r only one but on line A. Complete tine B if applicable) a� — - <br /> A. E]New System ,qi Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System("plain) <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/Component/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>2A in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVrteatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(af) Dispersal Area Proposed(st) System Elevation <br /> 300 . S' &ors I GDO C?/. $-0 <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units y o$ v <br /> New Tanks Existing Ionic; "' o ;; <br /> L�U cz m y iw r7 P. <br /> Septic or Holding Tank 06,a QOO <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) T Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rte/c /7'0 lel,h s <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J+771ae ,` 3S W-e6S7�N/ UJL S�f893 <br /> VIII.Court /De artment Use Onl <br /> Approved ❑Disapproved Permit Fee Date llssaved Issuing ent lure <br /> ❑Owner Given Reason for Denial S 0,?,5 .3 f me ki <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Aftach to complete plans for the system and submit to the County only on paper not tea than a Vr s It bushes In du <br /> SBD-6398(R.01/07)Valid ttw 01/09 <br />