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• t • De - Ii i Q1 .- 4x`1/33/ <br /> commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 D NA.) e- <br /> EJ1sCC)fls i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 6781 1 q <br /> Sanitary Permit Application .4ate•Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental i�` �t,} o V <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 <br /> 6Y e A- +i�.a A k< 0506 3) (1 -051g <br /> Property Owner's Mailing Address Property Location <br /> loo4 ( Lt.t \iC,\\Y• 2ci Govt.Lot <br /> City,State Zit Code Phone Number 3 a <br /> a '] j.�:� '/., �t '/,, Section <br /> M'f . 1 ' l r'C t,J . 5 '. 5 7 cT S)3 '+3 5 (circle one) <br /> IL Type of Building(check all that apply) Lot# T N; R <br /> ° ®r W <br /> IN 1 or 2 Family Dwelling-Number of Bedrooms .3 Subdivision Name <br /> Block t! <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ®Town of Pe.`s"C'i <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A" ❑New System KR ep lacement System <br /> ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 1 <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> El 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(sf) System El 'ation , <br /> LI5 C t (v 35 0 750 9b.t�� i.,1� g6,3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units az g '$ o <br /> New Tanks Existing Tanks e y , J a c,S <br /> X U h ., u I iE e E <br /> Septic cr.Fletding Tank /6 0 /t C Ct <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> Timothy J Jelle J �p <br /> i � ^-'( 227525 608-845-7456 <br /> Plumber's Address(Street.City,State.Zip Code) 'JJ <br /> 501 Commerce Parkway Verona Wi 53593 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issu- gent .-:gnatu <br /> XA.pproved ❑Disapproved 27 0.) <br /> ❑Owner Given Reason for Denial S✓`O --2 7-06° '/ " / 74e4�ti <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> l`s c Etac i to r J pI L pia system and submit to the County only on paper not less than 8 1R i 11 inches in size <br /> SBD-63 .01/07)Valid thru 01/09 <br /> 4 L AUG 2 7 2008 <br /> Public Health MDC <br /> Environmental Health <br />