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. 7 . µ f <br /> commerce.wi.gov Safety and Buildings Division County._ <br /> 201 W.Washington Ave.,P.O.Box 7162 a,V k_ <br /> i SC•n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 518 038 <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 <br /> Property Owner's Name Parcel# <br /> Ltsa 11rC cjr Den -oS3 - SCID- 1 <br /> Property Owner's Mailing Address Property Location <br /> 7 3 ( b s'i---- QA Govt.Lot <br /> City,State '• , Zip Code Phone Number &IA rV. 61..2 1, Section 5 <br /> 1 ck pti0.,v_;'Q., W \ S3 5 60 ' �5 "S i ci y T g N' R (� circle once) <br /> IL Type of Building(check all that apply) Lot# �'^ <br /> .gr1 or 2 Family Dwelling-Number of Bedrooms 3 Ca Subdivision Name <br /> Block# . <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use umber ❑Village of <br /> • A^5C1 g Town of <br /> line IIL Type of Permit: (Check only one box on line A. Complete ne B if applicable) r�lfL�.,� j,i,'�, 1 M <br /> A. lEadif tioEo Elistr '1 <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only er r S�s`it m,(;� ) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber -.t rvious);ggpjt I m er Motte Issuer. <br /> g ❑Permit Transfer to New JuN 1 <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) ``,t►�,,t�' ����+y p <br /> a Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound PitO f.CbliKitx6il 961PC <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment De tnVlfOnRlental Hearth <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 /> 450 r6 -7 'G goo 9�a /9ta` <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .0 c o <br /> New Tanks Existing Tanks u m b 5 <br /> L U rn ii C7 F. <br /> n <br /> Septic or Holding Tank 100 0 WOO I t�a,1. 0.Yea o/ ,x <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) Plum Sign MP/MPRS 5 Number Business Phone Number <br /> Timothy J Jelle <br /> ?i,v, 2 27525 y� 60R-845-7456 <br /> Plumber's Address(Street,City,State,Zip Code) l/ <br /> 501 Commerce Parkway Verona Wi 53593 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent S <br /> roved ❑Disapproved 5 / <br /> ❑Owner Given Reason for Denial Sao. — C/a 6 08 /1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> --X t- hG 5 7 - fr. k1/V(l5. VO� <br /> 6 <br /> al 0_5- 10-e,- rd cl-e <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/1 a 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />