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commerceml.gov Safety and Buildings Division County �J <br /> 201 W.Washington Ave.,P.O.Box 7162 /34 ra i rr <br /> tLseonsin Madisoq WI 5 37 07-7 1 62 Sanitary Permit Number(to be filled in by Co.) <br /> 4tpartmerd of Commerce C./,.. ,/ -/�7 <br /> Sanitary Permit Application State TT�r`Jamu.fim Number <br /> In accordance with S.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental /vG(/1 CNt <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address inanumin than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 171 <br /> see in accordance with the Privacy Law,s.15.14(1)(m),Slats. Sl <br /> L Application Information-Please Print AB Ldortnation el 4 7S 7 L o r,f G k 11 l 1 <br /> PropeCj Owner a Name Parcel# 0 7-0 3 d-d-4 '✓ - �" <br /> Jaaatae Gwlley pZ. bpd- f� / 3eeo <br /> Property Owner's Mailing Address Property Location <br /> / 3 44d e/7r ti /Qv e N• Parcel to <br /> Govt Lot �i Sec.33 -+— <br /> City,Stale Zip Code Phone Number ALI <br /> Y, 5W Y., Section 3 <br /> MA le 6elove `0 IV SS36 '1 763 - AII49 0�.3/ (circle one) <br /> IL T of Build' T �1/ N; R /G E o <br /> ,ra+.a.Type Ing(check all that aPPIY) Lot# <br /> ON or 2 Family Dwelling-Number of Bedrooms 01' Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> El State Owned-Describe Use CSM Number ❑ Village of <br /> Town of 5 v rJJ <br /> IIL Type of Permit: (Check only one boa on Ihte A. Complete time B if applicable) <br /> A. ❑New System y .Replacement System ❑ Trealment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑PermitTransfer to New List Previous Permit Nordem and Date Issued <br /> Before Expiration Owner <br /> IV.j1pe of POWTS S stem/Com onent/Device: Check all that apply) <br /> A Nov-Pmssmized In-Ground D Pressurized In-Ground ❑ Al-Grade ❑Mound>24 in.of suitable sod ❑Mound<24 in.of suitable soil <br /> ❑Dolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V )h ersal/Treatrumt Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> Sep 7 l y A N ?,t cj.t.c <br /> tVLTank Wo Capacity in Total #of Manufacturer <br /> Galloon Gallons Units eNew Tm�ks Existing Tm�ks Uepc or Holdvig Tmilr <br /> 0 0 Bea i s i�.s X <br /> Dosing Chamber <br /> VIL Respon" ity Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's S/ignature MP/MPRS Number Buaineas Phone Number <br /> ,8/4/L /f/e k,�J / /y dl drsf�s/ 7/S- g/�6•YI,S�� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> o) 77ti0 A/W 3S ta/ 661{t, ( tiL .s5a893 <br /> V11L Court /De artment Use Ohl <br /> Approved ❑Disapproved Pe11i[F Dat/e hsued Issuing Allen[ tore <br /> ❑Owner Given Reason for Denial Sip A,194 V 211 <br /> IX.Conditions of Apprmal/Reassim for Disapproval <br /> Attach to complete plam(or the syahm and wbmit to the County only on paper not km than 8 in s 11 Inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />