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'7/------ r_ Check TO W33`7 ateTb y9sl <br /> commerdc.gov Safety•and•Buildings Division Coun <br /> AUG W3s}iirrgon Ave.,P.O.Box 7162 a ti <br /> /iscori„ G 2 7 v Madison,. 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 51(V I a3 <br /> t L. <br /> Sap vto nr�` t plieation State Transaction Number <br /> AO f cxl D' <br /> In accordance with s.Comm.83.21(2),lk., uc e,su mrsston of mki5'tot4it 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 f/�; <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. t?e.`C VN K C.c_.;‘,..,..\' - <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address (� Property Location <br /> 1(C t `-cx v,2, 1-(y t,-)'c Govt.Lot <br /> City,State 1 Zip Code Phone Number r. r a <br /> �y 433'4 N a ie, N w /�, Section <br /> 5u N I 5 J 5 e e -iao co t (circle one) <br /> IL Type of Building(check all that apply) Lot# T N; R G <br /> Et rW <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# C,e\v- s€ .;‘<0011_. <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSM Number ❑Village of <br /> 2 Town of %V`. K <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. kg New System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumbet List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ig 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 /> hoc /Sow /.5/a `13.1 -Sit .3,- 11.51 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o$ _° <br /> New Tanks Existing Tanks w 2 v u G <br /> V in 2 :n LT,3 a. <br /> Septic or Holding Tank i 3 0 /7o d 1 Oa l fV eL V A X <br /> Dosing Chamber -150 75) I a l A <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Timothy J Jelle y 227525 <br /> N-� -� 60R-845-74.66 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 501 Commerce Parkway Verona Wi 53593 <br /> ,,VIII.County/Department Use Only <br /> ,Y�-Approved ❑Disapproved Permit Fee Date Issued Issuino�ttrr,,,,t Signature <br /> ❑Owner Given Reason for Denial <br /> $337.co £�-ZB�DS �z �, �GC-� <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 1/1 i 11 inches in size <br /> SBD-6398(R-01'07)Valid thru 01/09 <br />