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• C) 011 .7o4-o`' <br /> -1"---_ 21)PJA ar7i4-1.�- <br /> co mmerce.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> tisconsin Madison,W 1 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce 51 20-0 / <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 uscd for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. PL d5 <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 11 e / 7i ....1) .�`9�y�fel— C/4r rf ,s-m�- oi£�— 6-711.—/iy- 9,3 — 0 <br /> < c�c <br /> Property Owner's Mailing Address Property Location <br /> /e0 C %l7 ' i:.;) / Govt.Lot \ <br /> City,State /� ` Zip Code Phone Number .5E 'h. SE y., Section //•De,vy d/J_ J, , S3 / c42 -3(/sz+ (circle one) • <br /> a T 7 N; R /f EorW <br /> II.Type of Building(check all that apply) ' L f Lot# <br /> or 2 Family Dwelling—Number of Bedrooms • 7/ / Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> • <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> / ,a 5-3 ,Town of 7 -4 ‹.. 6C. <br /> yp <br /> I e of Permit: Check only one box on line A. Complete line B if applicable) - �✓ 6i, - <br /> A' New System y 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ,Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.ofsuitablc 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(sO Dispersal Arca Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o oo$ <br /> New Tanks Existing Tanks c u y <br /> u F <br /> n-u in N rn P.v i% <br /> Se is o Holding Tank /28(, — /2-4.q V 2 /ec: . -, y <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) Plumber's Signature <br /> PP/MPR S Number Business Phone Number <br /> Aktalec w - /N n Lt;/2 .JTa'-,c.Z 1.). --)-1-, Oc)0 i 6s- b D 6'4f?l -f <br /> /o <br /> Plumber's Address(Street,City,State,Zip Code) , > -� <br /> ei3 eXti ''lc '' t',tia,"- . tc�._ ("■-);. -S 35i? <br /> VIII.County/Department Use Only <br /> ❑ Disapproved P�mitrF�ce_ Date IssdIssuing A: nt Signature <br /> ❑Owner Given Reason for Denial 53 2C) „725°C:5-0, _i t- - . ir <br /> IX.Conditions of Approval/Reasons for Disapproval I�� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in xll i 1 as in sizt:AY <br /> �.i 2 8 ....ii <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> Punic Health MDC <br /> Environmental Health <br />