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commerce.wi.gov Safety and Buildings Division County ! <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> isco n s i n Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 5q/033 <br /> Sanitary Permit Application stare Tra e6°"No r <br /> In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate Owt 4 <br /> m <br /> governmental unit is required prior obtaining a sanitary permit. Now: Application forms for state-owned Project Address(if different than mailing address) �VT <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for /1 / <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stars. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name / Parcel# O ] 3 <br /> 11 t �( IS <br /> T -1.J o 5 oF' 00,E <br /> Property Owner's Ma iling Address n Property Location L f <br /> / A 9 s O /r6� e_ F r, Govt. Lot 1_Z <br /> City,State Zip Code Phone Number iA, 14,Section �2 3 <br /> 417 .(circle one) <br /> IIm,'�LType of Building(check all that apply) _ Lot# T �� N; R 5 E or <br /> 5N or 2 Family Dwelling-Number of Bedrooms '—� Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑ State Owned-Describe Use CSM Number ❑ Village of -i <br /> )R-Town of , ) A C S O <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' El New System iq Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) <br /> YL,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. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sh System Elevation <br /> y� <br /> - _7 K y.3 yv, oto <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> N <br /> Gallons Gallons Units . o v Y <br /> New Tanks Existing Tanks v o <br /> Septic or /00 () 0 007�- <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> ' <br /> Plumber's Name(Prin [) Plumber's is Signa lure MP/MPRS Number Business Phone Number <br /> � <br /> /� � .� zz�6 97 ivy �;z C <br /> Plumber's Address(Street , City,State,Zip Code) <br /> V111. County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Dante Issued <br /> �yR Issuing gen ignalure <br /> 11Owner Given Reason for Denial S 30^"o /U K710 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size <br /> SBD-6398 (R. 02/09)Valid thru 02/11 <br />