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'v <br /> . _ <br /> D ECE1VE <br /> " ktfti <br /> County <br /> commerce. Safety and Buildings Division ty <br /> 8 ,„' 201 W.Washington Ave.,P.O.Box 7162 �tt�� <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> G4 Co 57805 <br /> —Public:Healll I t DC , State Transaction Number <br /> Environmental tea' .i t • +, Permit Application <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(1Xm),Stats. S tf'15� �� -. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> jlIz Is o;-I G—v+a./rs I fru4-A-)✓-S v706— l v(— Co 122-- C% <br /> Property Owner's Mailing Address Property Location <br /> 3a S6 /Jroo/c./G, %t Dr. .'c. Govt.Lot <br /> City,State //i Zip Code C� Phone Number r SE y,, N&%, Section �� <br /> �7'O[.a. A l4-'1 L4) 53s 89 66/ — /SJ y (circle one) <br /> T N; R E or'W <br /> II Type of Building(check all that appl Lot# <br /> �1 or 2 Family Dwelling-Number of Bedroo s 4 t-2_ Subdivision Name <br /> Block•#. Ski RA G(G,e at. <br /> ❑Public/Commercial-Describe Use - ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use e/Town of i\4 Ai 1QlSV\ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> U New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal CI Permit Revision Cl Change of Plumber <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 1'JNoo-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank Cl 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(st) Dispersal Area Proposed(sf) System Elevation <br /> &OD II+ /5-o d /S% 2- %0ff y /o l� �UG 9". <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o c, `-' <br /> , U .. <br /> New Tanks Existing Tanks u ° a ° .8 m a <br /> 0 <br /> -r t�,� I a U in ; rn w.C7 a. <br /> Septic or Holding Tank ' Z!�t7 1 4L i _ ,�'I e A/,1 d <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) <br /> PI`' ber'sSignature MP/MPRS Number Business Phone Number <br /> 1'161 irtti'v 'IA) � i YNhC I,-).. ,,. ). /71,- J Plumber's Address(Street,City,State,Zip Code) <br /> x°'-)15 C I t ` lG L-V Ltitcl -ize-1 , 6\.1( L-9D -7 --) 7 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agen . :. .. re <br /> pproved ❑Disapproved $3a.0 I//1 /D Q <br /> ❑Owner Given Reason for Denial / CJ <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 r/1 x I I inches in size-- <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />