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(f %....1%-.14 1 U-t-r <br /> -Ds3c: to 4 a <br /> commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 pre, <br /> tis- <br /> co n S I f Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Depsrtmertt of commerce 5 I 7 9 SS <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.I5.04(1)(m),Stets. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> L01-9,41A A h%► t Ke-r1 GSa7--052- 91Ko-C7 <br /> Property Owner's Mailing Address Property Location <br /> 9t55 IS Govt Lot <br /> City,,Statee- Zip Code Phone Number 5E y. M AI 4, Section e <br /> MAtorv.ar to w\ (circle one) <br /> rj ob T 8 N; R 7 E er-W <br /> II.Type of Building(check all that apply) Lot# <br /> 13)1 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block-#, <br /> ❑Public/Commercial-Describe Use - ❑City of <br /> •❑State Owned-Describe Use CSM Number ❑Village of <br /> 11579 SiTown of <br /> III.Type <br /> e of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. M New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑O, odic tietio trig , °a <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Permit Number and Date Issued ` <br /> Before Expiration Owner MAY 1 5 2008 <br /> O r <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) I i <br /> 53/Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ oun oil I <br /> ub lc Health MDC <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Devi .alai i,a • a <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 .1 4043 72o 95 71 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units S g <br /> New Tanks &fisting Tanks 1 u c 13 ,—m VI <br /> w a 0 n r h a 0 <br /> Septic outing Tank t L. O -- IUt7O 1 ME 4 <br /> (Dosing csaC, — . Lem t 1 ac ,� <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 /MPRS Number Business Phone Number <br /> > c(.row Vv• Murk_itc .` t,a 220((,S 83(-$I d3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved ❑Disapproved <br /> / ❑Owner Given Reason for Denial S 330 5/9/08 - <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 8 112 x 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 • <br /> • <br />