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commerct:.wi.goV Safety and Buildings Division CounryrQ r <br /> at 201 W.Washington Ave.,P.O.Box 7162 I <br /> isconsin Madison,WI 53707-7162 SanitaryPermit Number(to be filled in by Co.) <br /> Department of commerce 53.2 1 4(v <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83:21(2),Wis.Adm.Code,submission of this form to the appropriate governmental C Roul ew <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POINTS are Project Address(if different than mailingaddress) r, <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary w <br /> purposes in accordance with the Privacy Law,s. 15. 1 m,Slats. <br /> I. Application Information-Please Print All Inforina i �.on Ii. vst K0 j <br /> Pro erty Owner's Name ,, � // Parcel# <br /> �� E'S W , 'S0+^ a o ]• al 3`1-/b-2S c2.Ano-o loon <br /> Property Owner's Maillii`ngg A'Adddress Property Location <br /> S J Govt.Lot <br /> Ci ,State / ISN004_T�3: <br /> Code Phone Number „�y, _V�% Section ;Is <br /> �Y r �,� IJ —0175 T 39 N; R uclE onW,dI.Type of Build ng(check all that applyLot# <br /> 4ul or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> ❑Public/Commercial-Describe Use Block <br /> 0 City of <br /> D State Owned-Describe Use CSM Number D Village of <br /> '/0I I-7 14Town of 144 eP tI0-" <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ 1O_ _ _ a <br /> A. A'New System ❑Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. D Permit Renewal ❑Permit Revision D Change of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POW IS S stem/Com nent/Device: Check all that apply) <br /> XNon-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) D PrcVeatment Device(explain) <br /> V.Dis ersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> O , S 900 a d 76.70 <br /> VI.Tank Info Capacity in Tocol #of Manufacturer o <br /> Gallons Gallons Units ,3 <br /> New Tanks Existing Tanks <br /> w` U vi <br /> Septic lidding Tank K <br /> Dosing Chamber 000 ' <br /> VII.Responsibility Statement- 1,the undersigned, ssume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum er's Signature MP/MPRS Nuother 3711- <br /> Plumber's <br /> usiness Phone Number <br /> CS �of r r ti�. 22Sz2 9 �1f d��P6o� <br /> Plum'-b-err'{s%Adddress(Street,City, ta[q Zip Code) / <br /> - /U 7 s f/rt CV Q�Sr �r r J i a <br /> VIII.County/Department Use Only <br /> Approved El Disapproved Permit Fee DateIssuedIssuing t gnature <br /> ❑Owner Given Reason for Denial $i,3 5�`'rn <br /> aw <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 in a 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />