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cornmerce.wLc ,' andiBwildMgs Division County <br /> 201 W.Wasktingten-�4ve.,P.O.Box 7162 1 re_, <br /> i �� "�n 4 Madison WI 53707-7162 Sanitary Permit Numlydr(to be filled in by Co.) <br /> 5tata'[rnnssctionNUmber <br /> Sanitary Permit .lpplicat ion <br /> In accordance with s.Comm.83.21(2),'iris.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a s tnitary permit Note: Application forms for state-owttod POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Corns torte, personal information you provide may be used for secondary <br /> purposes in accordance with the privacy_Law S 15.t?M1(i)( ),Stflts. • I V>^Nt r W�C y05 <br /> L Application Information•-Plea.e Print All Information parcel# <br /> Property CT:ma's Name <br /> Scil.1. l1a a-Q - lay;- 2(:>1-0 <br /> E) <br /> Property Location <br /> property Owners Mailing Address <br /> >( L t, cl 4+O Govt.Lot <br /> 1� � W 1rrf.ba�C� _ , � <br /> City.State Zip Code Phone Number Sy 'J v,, Stn! '''A,Section 16 <br /> (circle one) <br /> Gtl ri(M W 1' L y 7014 T 7 N: R, i Etc W <br /> Il, ype of Building(check all the t apply) Lot# '— - <br /> ,f � Subdivision Name <br /> irr 1 or 2 Family Dwelling-Number of Bedrooms_ `t <br /> Elvcict+. <br /> U Public/Commercial-Describe Use _ City of —• <br /> C,SMNumber D Village of <br /> Q State Owned Describe Use -� GiTown of Mliki V-^(6^- <br /> M.Type of Permit: (Cheek only one box on line A. Complete line B if-applicable) <br /> A' EdNew System ❑Rept tcernent System 0 Treatment/Holding Tank Replacement Only •O Other Modification to Existing System(explain) <br /> -- List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal y 1:1 Fern it Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner — <br /> N,x e tall__!li'S S stern/Col sponent!Device: Check all that a. I <br /> a Non-Pressurized In-Ground ❑1 ressvrized In-Ground ❑At-Grade ['Motmd>24 in.of suitable soil 0 Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Disperse Component(explain) <br /> 0 Pretreatment Device(explain) <br /> ✓ Dispels*IITretttment Area In ot�nktion: <br /> Dispersal Area Required(sl) Dispersal Arab Proposed(st) System @lev tion S e <br /> ��how(Bpd) Design Soil A tplit,�tion Rate(gpdsf) �P � -�- <br /> VI.Tank Info Capacity in <br /> Total if of Manufacturer at <br /> Gallons Gallons Units tl E v <br /> ri T- - <br /> NevTsnlB ' ExistiagTanks o c Sg � � i <br /> U at H s LV o, <br /> Septic orabolding Tank 1� IZa^ 11 M6clZie 't <br /> - - <br /> Dosing Chamber �C a — - - - <br /> V1iI.Rr sponsibilitY Statement- ,the undersli ned,assume responsibility for Installation of the POWTSSssh�RS Nhe attached Blur rte Phbnc Number <br /> Plumber's Name(Print) Plumber's Signature <br /> Plumber's Address(Street,City,Stott Zip Code) <br /> l ,,i3 TI-l-4■VV GL i,w..,_er .r. f i 53 ".1 / <br /> VIII.County/De�,arimcnt Use I to issuin A cat Si• re <br /> �,.J Permit Fee Date Issued 5 1 Q f g <br /> QD Approved i3 Dimpproved �'c3 1 b p <br /> /\ SQ,Q.— s <br /> ❑Owner Given R anon for Denial l O �+ <br /> "iX-Conditions of Approvnl/Rc sons for Disapproval <br /> A <br /> -------------. <br /> Aoath n complete 1>ta ms For the sysrcrn and,ut rn t ie the County only en piper not lag than S Ina 11 ipCMea in sine <br /> SB1)-6396(R.01/07)Valid thru J1/09 <br />