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• <br /> .- <br /> V`-1 -4 -DQlt .1-734,k (iiit. 4 aol R <br /> commeree.wi.goV Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 r>4t■e• <br /> ISCO fl S Madison,WI 53707-7162 Sanitary Permit Number filled in by Co.) <br /> LS <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.8321(2),Wis.Adm.Code,su emissi^, ,f this form to the appropriate ovemmcntal , <br /> unit is required prior to obtaining a sanitary permit No ppl o o la c.-o�pntd 1S are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal i , , tjo ou o u for �c�rtd <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm I Ln dLt by. <br /> I. Application Information—Please Print All Info ga, n Try <br /> Property Owners-Name--_- :.._ I I JUN 1 9 2008 J Parcel# <br /> E,;c at Lynn Lars►,t —J 6l oS-214-621(3-S <br /> Property Owner Mailing Addre.X Property Location <br /> Pubic Heath MDC <br /> 64018 /one &►'bate IAJay Envir ,n; . l`:ii 1_+.'&th Govt.Lot <br /> _ <br /> City,State Zip Code Phone Number • y., SE V, Section ri <br /> Motir.ItSCA^t W1 5311° 226 412 ` T '"7 N; R g (eirclEo <br /> II.Type of Building(check all that apply) Lot# <br /> l 23 Subdivision Name <br /> 1 or 2 Family Dwelling—Number of Bedrooms '1 <br /> Blpck•#, V.40,1 4-H U <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned—Describe Use t Ad iQ h7V1 <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. C]Ncw System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision g <br /> Before Expiration , Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> M 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 /> (spt, 4 l90 ISM 95 Sr} 94,5' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ,,, e °.' .„ •`-' <br /> U � <br /> Now Tanks Existing Tanks o o 6, D B a m co <br /> P,U in U) w tJ n- <br /> Septic or Holding Tank 12 8 — r2 e4, 1 MADE x <br /> Dosing chamber <br /> VD.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 1.W/MPRS Number Business Phone Number <br /> 14)04.C.4/4 W. (loin -- 1 — zA.)- -) -f 27-o16S 831. 0103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (aS 13 . CM- i- wa y w 1 5'39,7 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved ❑Disapproved a <br /> ❑Owner Given Reason for Denial 4 Sao.— G/a3 l o TA/N,S <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 S 1/2 x 11 inches in size - <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />