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. , j 1 398-`L <br /> ti <br /> eommerce.wi_gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Qa�P <br /> i sco n s s Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 5l '7 956 <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 '2 O 14 /_Uw C-'/' L ell <br /> Property Owner's Name Parcel <br /> KKu)w .i ul se 0(-1 6/0611 -,2-s -- C325-0 <br /> Property Owner's Mailing Address n Property Location <br /> O 1 0 1 O Lo P ' d ' <br /> t - Govt.Lot <br /> City,State Zip Code Phone Number sta./ 4,,,,, t/,, Section <br /> o2,S <br /> S 1e,aqh�n /U4- �l'3 set (circle one) <br /> H.Typ of Building(check all that apply) O ( Lot T N; R �( E or V✓ <br /> lir I or 2 Family Dwelling-Number of Bedrooms 3 / Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use ' p <br /> CSM Number ❑ Village of <br /> e4S <br /> / ig Town of f z-' 5,ri 1j <br /> a `1 3 0 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ❑New System g Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> KNon-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.DispersalfTreatment Area Information: <br /> Design Flow(!(gpd) Design Soil Application Rate(gpdsf)fl Dispersal Area Required(s� Dispersal Area Proposed(sf) System Elevation <br /> 1.1 SD t 6 •? 1-0 q Cl 6 P''..5 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units L u " <br /> New Tanks I Existing Tanks _ U , g r <br /> 4: c:/ :n 41"5I r; <br /> • <br /> Septic or Holding Tani r�3{�O I /oh I /nt w 0- <br /> ll <br /> Dosing Chamber I / / 667 0 a 6 o I <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumki02,341-eiii ber's Signature I MP/MPRS Number Business Phone Number <br /> 16.Anei-A /27 i'e - ii / I �C(','- ,Y`t'%- 6.77( <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (l <br /> ? 3 I Tart ' e\ � I 6-1"-/t:_. Us-)! `• A <br /> VIII.County/Department Use Only if <br /> Approved ❑ Disapproved Permit Fee Date Issued Issui t i <br /> Q <br /> ❑ Owner Given Reason for Denial S' -1. 412-1 1 O v `�`•' A`r4�e ' <br /> IX.Conditions of Approval/Reasons for Disapproval��t /Pc, (L-tr= - t / j fj <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1G x 11 inches in size <br /> SBD-6398 R.01/07)Valid thru 01/09 <br />