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a <br /> commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> tOsconsin Madison,Wl53T07-7162 Sanitary Pcr tIlcdinbyGo.) <br /> epartmont of Commorrco 5/83.5 oti <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with s.Comm.33.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application fonts 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 t m Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel N <br /> /Ir - C y 1 �e`S " o9/ <br /> J„ /91-1r e%47- a <br /> Property Owner's Mailing Address Property Location <br /> 4:20 i rCA.S - ' - Y`v ,�-�• Govt.Lot <br /> City,State O_� Zip Code Phone Number Al �''NUJ ,h, Section c /1 <br /> .S i PY Il�et. Wr 5136-go T 9• N .R /I( EorW <br /> 1 (/ L)) Lot q <br /> II.Type of Building(check all that apply) � �„ Subdivision Name 1 <br /> _- I or2 Family Dwelling-NumbcrofBedrooms NOr""i,Jls.7 j•Q FI i <br /> Block N <br /> ❑PubtidCommereial—Describe Use• ❑City of <br /> CSM Number ❑Village of 7 <br /> ❑State Owned-Describe Use Town of P r i s /°I <br /> III. cr u. Check only one box on line A. Complete line 13 if applicable) • <br /> A. "(New System ❑Replacement System ❑•frealment/fioldingTank Replacement Only ❑Other Modification to Existing System(explain) <br /> ,, List Previous Permit Number and Date issued <br /> B. t..`Pcnmit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS Systens/Consponcnt/Devicc: (Check all that p r"' <br /> ❑Non-Pressurized In-Ground ❑Pressurized in-Ground ❑At-G de 1 Mound>24 in.ofsuitablc soil) ❑ sound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) <br /> ❑Pretreatmc c(explain) <br /> V.D1sgsersaVPrentnscnt Are rfofmati�on: Dis rsal Arw Proposed(st) System Elevation• <br /> i n Plow( pd) Design oit,Application)Rate(gpdst) Dispersal Arcs Required(al) pe U�� A) I S.se �� io. <br /> . iT W nfo Capacity N of Ma ufaclurcr u u <br /> YI <br /> -'� Gallons Gallons Units p U � � <br /> New Tanks Existing Tanks rz a IC A w . <br /> • <br /> Septic or Holding Tank /L v c, /2-06 3 ..„00-4ea c.12...• 7. <br /> DosingChanibcr 65 T6 65",) / V x- <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for itistallatlon of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) 4 Plumber's Signature IIWP/MPRS Number Business Phone Number <br /> re-4,./ te..3 /4 e4`n (2 _..../ esL I.A.J. cl-ae)/6s tog—k31- F/63 <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> 6 e 13 �rl+ rt ft..." wa.x.J..v,c l'11.t-, ('`),• • -3. i / <br /> VIII.County/Department Use Only <br /> PcrnsitFec�� Date Issued Issuing gent Signatur <br /> 11 Approved ❑Disapproved S <br /> 1 <br /> ❑Owner Given Reason for Denial s ■ -� i <br /> IX.Conditions of Approval/Reasons for Disapproval . <br /> � <br /> �At Attach to complete plans for the system and submit to the County only on paper nol less than 314111 Inches In tine <br /> Cti LOADS . <br /> SBD-6398(R.01/07)Valid dm 01/09 <br /> DO —.So ' <br /> • <br />