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•OCT 8 200QQ CikcCk rr `15578 bi3J'n a 71,03 • <br /> corn merce.w.gov Safety and Buildings Division County <br /> it <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> i SCE s 1. Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of9ommer to 5'/ l <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 <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 /4 /1/r'- .6"..,_ Q'r•\ <br /> Property Owner's Name Parcel# <br /> / /� <br /> ^e rse-1 1 c - IZ a 3 6 r e it t'Le r- J t i, 'e l•/ec'r cj eJ L (r !Cr 3 S/- e0d c' - / <br /> Property Owner's Mailing A J�1, Property Location <br /> 5-1 6 in <br /> / /L i'r/i7 e v e./c- �r' Govt.Lot <br /> City,State J Zip Code Phone Number 3 S <br /> • <br /> // // /, ill�c /, Section <br /> �lR..d. /3 d ti (.C_1?z a g 7 c f 1 Qe'- 33K-. 191 S--,7 <br /> //'' (circle-Qne) <br /> IL Type of Building(check all that apply) Lot# T �p N; R j C�(!a ar IV- <br /> IL <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms V Subdivision Name <br /> Block# 1 ct («rc. 1 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of i."1/4 A tN- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. CI Permit Renewal ❑ Permit Revision CI 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 /> '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 Elevation <br /> VI.'Fank Info Capacity in Total #of Manufacturer f l <br /> Gallons Gallons Units D ` U-0 I 9. <br /> New Tanks Existing Tanks ,2 = v u m EA <br /> o <br /> U 'Cr: H s [=V 0. <br /> Septic or Holding Tank i . .g c ( 1 V& 1 Ie _ /4 w <br /> Dosing Chamber 1 0 0 if t LCD( �( <br /> VII.Responsibility Statement- 1,the undersigned,assume responsi ility for installatio of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) �1 Plum natur � -- /� MP/MPRS Number Business Phone Number <br /> ) f t,L1�/vcR CRo Y3 \ lc <br /> Plumber's Address(Street,City,State,Zip Code) t .� <br /> 71 c{f- 11 � C <br /> Co ct1- -1-- <br /> 3 � ot,vE Ai 5 J )7) <br /> VIII.County/Department Use Only / I <br /> pproved ❑ Disapproved Permit Fee Date Issue Issui t • :en-fii:na.'re , I <br /> $ �2 10110 log �L::-'-'�. /440" ' - ' <br /> ❑Owner Given Reason for Denial ` <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 t/2 z 1 I inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />