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i commerce.wLgov Safety and Buildings Division Cozen <br /> 201 W.Washington Ave.,P.O.Box 7162 tad(12C - <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> O.Pars+s!.srt a ccmnr.ro. Z 8 <br /> Sanitary Permit Application SMWT actiioon'Number <br /> In accordance with s.Comm 83.21(2),Wis.Adm.Code,submission oflhis form to the appropriate governmental r,N-L y 1 <br /> unit is required prior to obtaining a sanitary permit Note: Appli n forms for state-owned POWTS are Project��Asddress(if different thaprnailing address) <br /> submitted to the Department of Commerce. , Personal information you provide may be used for secondary C71&M6;()n7 s l` PwAfe- <br /> u ses in accordance with the PrivacyLaw,a,15. I m Stats. �J <br /> I. A licationInformation-PleasePrintAllInformation <br /> Property Owner's qame,ULI._ Parcel M TX zLZZ'7 <br /> df-03L-2•y/-16.333 63 c000isesero <br /> Property Owner's Mailing Address <br /> Property Location <br /> 15183 (nrd'o.(/_ tjo <br /> Govt.Lot <br /> City,Sista 1 ,y-� _ZiD Code •' - Phone Number 5_.) ''/ _ Sectionn��};,, <br /> 4'/1clote(L- ala 56630' ' Lelz-631ir- qqO�' T 41 N. R /(circlE"L% <br /> II.Type of Building(check all that apply) Lot a sL <br /> I or 2 Family Dwelling-Number of Bedrooms Z Y Subdivision Name <br /> Block a <br /> � Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number Poe,11z-"77/ ❑ Village of <br /> mA,a�_2a3i 0 Town of C; uJ;55 <br /> \/1 3 BJ 40 2- <br /> III,Type otPermin (Check only one box on line A. Complete One B if applica le) a_. 33 _oa S <br /> A r� <br /> ,u New System ❑Replacement System ❑Treaunent/Holding Took Replacement Only ❑ Other Modification m Existing System(explain) <br /> B. Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Ntunlxr and Date Issued <br /> Be(ore.Fxpuedon Owns <br /> ,I\'.T e ofPOWTS S stem/Com onent/Device: Check ell that a I <br /> /1 Non-Prcssuriud In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.ofsuitablesoil ❑ Mound<24 in of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Da' ersaVrreatment Area Information: <br /> Dc sign Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arca Requlred(sf) Dispersal Area Proposed(all System Elevation <br /> O <br /> D • 7 X32 �Sa '9z.o s 4aFo' <br /> fo Capacity in Total a of Manufacturer <br /> Gallons; Gallons Units `o c <br /> New Tanks Existing Tudu ta u U N _ u <br /> i V rn vui w U a <br /> a-9 <br /> r <br /> Statement- I,the undersigned,assume respoasibili for installation of the POWTS shown on the attached plans. <br /> PI MOtM1 of l l' tr & EXCAVATION PI s amreh4P/5MERS Number Business Phone Number <br /> e:RQ4Y7? <br /> Plum pt, U, Ocie)74 R_PR'3C_7A On <br /> , e7p4 <br /> VIII.Coon a artmeat se nl <br /> Approved C1 Disapproved Permit Fae Date Issued Issuin Ag S' awre <br /> SZ 10K <br /> C3OwnarGivenReasonforDenial 325 <br /> IX. Conditions of ApprovaVReasons forDisapproval <br /> Attach to eompleu plans for the system and submit b the County only on paper nos leu than a w x 11 inches In size <br /> SBD-6398(R-01/07)Valid thm 0 1/0 9 <br />