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commerce.wi.gov Safety and Buildings Division Counryrz <br /> 201 WWashington Ave.,P.O.Box 7162 IJ 4 r It e <br /> W. � { <br /> is e o n s i n Madison,Al 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> tr.epartment of Commerce <br /> 1Orion Number <br /> m_ rth <br /> Sanitary Permit Application State T� W <br /> //��^��^' �� 0)In accordance with S.Comm.83:21(2),Wis.AdCode,submission of this to=to the appropriate governmental C M/_1f 1 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) , <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary u i <br /> purposes in accordance with the Privacy Law,s. 15. I)m,Slats. <br /> I. Application Information-Please Print All Information 016Lk ]wck 4axe <br /> Prop j Owner's Name Parcel It <br /> t �fe EIrL a K ��33�� 07-0/2.2• ,$-.3z•� 0/-q7�- <br /> Propertny Owner' Mailing Address C y Property Location <br /> J I Govt.Lot <br /> Ciry,State Zip Code Phone Number 167 1/1, S 45 y, Section <br /> A�tLjtt+tt4H �, S O/ _ circle one) <br /> T�./_�N; REor� <br /> II.'Type of Building(check all that apply) Lot p <br /> ❑ I ort Family Dwelling -Numberof Bedrooms y Subdivision Name <br /> Block it <br /> ❑Public/Commercial-Describe Use ❑City of <br /> D State Owned-Describe Use CSMNumber ❑ Village of <br /> 1.7 IxTownof_ JacK.sO)A <br /> P ys <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) Qa_ - <br /> A- <br /> 18 New System El Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B- ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owns <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> - <br /> �KNon-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.Dis ersaUTreatment Area Information: <br /> Denim Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(at) System Elevation <br /> 3 c o r 7 L';L9 Lq Zcf 93.So <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks i -u <br /> o v <br /> a U rig b rn 'w U W <br /> e c rHoldinSTaok v/ O f <br /> _ li LtJf�PS'Ci' <br /> Dos'ne Chamber <br /> VII.Responsibility Statement- 1,the undersign ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu tier's Signature MP/MPRS Number Business Phone Number <br /> Nets kdev r It QICI Z2S2Z <br /> Plumber's Address(Street,City,State,Zip Code) f <br /> JA)Id <br /> VIII.Count /De artment Use Onl <br /> He Approved ❑ Disapproved Permit Fee Date Issued Issuing tSigna <br /> ❑ Owner Given Reason for Denial --525,15' 26(?, <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plain for the system and submit to the County oaly on Paper not less than 8 In z Il inches in size <br /> SAD-6398(R.02/09)Valid thrn 02/11 <br />