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ON COMPUTER/SCANNEL" <br /> Ahk eommememl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 644 r n e)q- <br /> 'Wisconsin Madison WI 53707-7162 Sanitary Permit Number(tobe filled in by Co.) <br /> Department of Coamn irce Y U l(!�l <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.2 1(2),Wis.Adm Code,submission of this form to the appropriate govemmeMal SU <br /> unit is required prior to obtaining a sanitary permit Note: Application fora for state-owned POWTS are Project Add—(if different flan mailing address) <br /> submitted to the Department of Commence. Peraoml information you provide may be used for secondary <br /> sea m aceoedaoce wish the Priv I.aw,s.mnativ-i Stats. 1R� <br /> L A Bwtim Information-Please Print AN hdormation 7`J 3r L45;0-- Lan A ( 11 <br /> nvperty Owaer's Name Parcel# <br /> 9I7o•o13� <br /> Property Own 's Mailwg dress Property Lecation <br /> City,StateGovt Lot <br /> Tip Code Phone Number Ye, Ye, Section et 9 <br /> kV ifs Gear Lake `nA/ 6s3-3979 (ncclo one <br /> 15 Type of Building(check all that apply) Lot# -7 Ty0 x; R /b B aQ0 <br /> 1 or 2 Family Dwelling-Number of Bedroom 3 `/3 Subdivision Name <br /> Block# <br /> ❑PublidCommercisl-Deuzibe Use <br /> ❑C' of <br /> ❑State Owned-Describe Use CSM Number �❑Village of <br /> pp Town of I,I/d tnIX' <br /> III.Type of Permit (Check only one hoz milli Complete fine B V applicable) <br /> A. ❑New System ❑Repleccment System gTrcalmenbHolding TankReplac®en[Only ❑Other Modification to Existing System(explain) <br /> B. ❑PermitRmewal ❑Permit Revision ❑ ChangeofPlumber ❑Penmit Tramferto New List Previom Permit Namba and Dalehsued <br /> Before Expiation Owner <br /> of POWTS 3 stem/Com rnNDevlee: Check all that apply) / 1 <br /> ❑Non-Prss'rized In-Graved 'jPomamu d In-Ground D AFGrde ❑Mound>21 inof suitable soil ❑ Mound<yt in,of suitable 11 <br /> soil <br /> ❑Holding Tank ❑Otha Dispersal Compoamt(explain) ❑Pretreatmeat Davice(explain) <br /> V.DispersatTreatruent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> V1.Tank hhfo Capacity in Total #of Mamd'acturer <br /> Gallons Gaflom Unica g° o <br /> New Tends ExiNing Tai e $ U b 'p <br /> LTCi CR3 in' iia Wei <br /> Seplica Holding Twik /p00 1000 <br /> NetChamber `00 <br /> 600 <br /> VIL ReaMAbifily Statement-I,the undersigned,assume res asibflity for installation ofthe POWTS shown on the attached plana. <br /> Plamba's Name(Print) Plumber's Signature MP/MPRS Number Business phone Number <br /> IF/e-/e- //o kr„.J /Zr tea.,Q dlstS'8Si 7/s 8 6 e- v/s7� <br /> Plumber's Address( trrs:l,city,Sute,Zip Code) <br /> 7760 ,el C Wif-&f le-, <br /> Wr tyg93 <br /> VI Cow /De arinrnt Use Orsi <br /> Approved ❑Disapproved Permit Fee DateArsued Issum sigma <br /> ❑Owaa Given Reewafor Denial S �r '('VUNC r07 <br /> IX.Conditions of Approval/Reas ins for Disapproval <br /> Attach to ossphte plso.far M ryans and sub”to the County ably oa paper was les than a res:Il Ivchea m ala <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />