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co rneree.wi.gov Safety and Buildings Division County p 'y <br /> 201 W.Washington Ave.,P.O.Box 7162 (7UenQI1 <br /> tlepartns,erd seonsin Madison WI 53707-7162 Sanitary`P2e mit Numbs be idled n by Co.) <br /> of Commerce J✓2 �� <br /> State Transaction Number <br /> Sanitary Permit Application p 85 92 <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Y&8 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are projectAddress(if different than mailing address) <br /> submitted to the Department of Commerce. personal information you provide may be wed for secondary jJ <br /> purposes in accordance with the Privjq Law,s.15.04(1)(m),Slam. -76 o <br /> 1. Application Wormation-Please Print Ali Worruation <br /> Property Owner's Name Parcel# <br /> 1 eVeamer E•%c1C3o l (�• <br /> CIS - 33do - os�op <br /> Property Owner's Mailing Address Property Lxation <br /> 9S O( ® AwY &46f- <br /> City,State Zip Code Phone Number Yy��Y' Section <br /> .�y 893 (circle one <br /> WeSIfev L✓� T 37 N; R /4 Eo <br /> IL Type of Building(check all that apply) Lot# <br /> Subdivision Name <br /> 1 or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑Pablic/Commescial-Describe Use ❑ City of <br /> CSMNumber ❑village of <br /> ❑State Owned-Describe Use /'✓l GO!"" <br /> Town of <br /> III.Type of Permit: (Check <br /> yy only one box of Bine A. Complete line B if applicable) - _ - - - <br /> A. E <br /> 44 Replacement System ❑ Treatment/HoWing Tank Replacement Only ❑Other Mod cation to Existing System(explain) <br /> B. ❑PermitReision ❑ Change of Plumber ❑Permit Transfer W New List Previous Permit Number and Date IssuOwnerIV. stem/Com onent/Devim: Check all that a 1 <br /> ❑Non-pressurized In-Ground ❑Pressurized In-Gmund ❑ At-Grade ®Mound>24 in.of suitablesoil ❑ Mound<24 inof suitable soil <br /> ❑Holding Tank ❑Other D'apenal Component(explain) ❑Pretreatment Device(explain) <br /> V.D' ersaBTrea""Ara Wormstion: <br /> Design Flow(gpd) Design Soil Application Rzte(gpdsf) Dispersal Area Required(ffIPA Proposed(at) System Elevationamp 9 300 96 '/ <br /> VI.Tank Wo Capacity in Total #oferGaRow Gallons UnitaIjis <br /> New Turks ExsG-Tanks vs SepticsHoldingTank 7,�0 7S0 ✓ <br /> nosingAC- <br /> clamber O 3d 0 / S/G.w <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation oflhe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/Iv1PR3 Number Business Phone Number <br /> /Z"c% a pis-86(a 4IS-7 <br /> Plumber's---- <br /> j <br /> ddr (Sheet, ity,State,Zip Code) <br /> 7 76 a /y'^ �S w ebsr�a� 3 <br /> VI Cour /De armnent Use Oral <br /> Permit Fm Dale issued Isauhr [signal= <br /> Approved 11Disapproved ` ��/ �p <br /> [I Owner Given Reason for Denial S 3`�5 .Z JAI/ V' <br /> IX.Conditions of Approval/Reasorns for Disapproval <br /> uta, mrnupleteptans forth •ysteuand.AW tithe Coudyads as Palernotlee thin8nita11inches Inrise <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />