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commerceml.gov Safety and Buildings Division County',?7 <br /> 201 W.Washington Ave.,P.O.Box 7162 U 0.r n e y- <br /> iseo n s i n Madison,R9 53707-7162 Sanitary Permit Number(to be Filled in by Co.) <br /> Department of Commerce 6211 ,31 <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 /> aes in accordance with the Privacy Law,s.15. I m),Slats. <br /> L Application Information-Please Print All Information SJ HO fCenf' A�pe. <br /> Property Owner's Name _y J. Parent k <br /> J�t�rspf Gfl,a,l,b,,rh C t( QC6 Oly dAl4 0A800 DO <br /> Property Owner's Mailing Address Property Location <br /> /&00-3 O/rti cr /?c(. <br /> Govt Lot <br /> City,State Zip Code Phone Number AL* �� Y., Section 1 T <br /> Web.-ti✓ WS S$8" :3 N; R�Eo T 39 (circle OMI_ <br /> IL Type of Building(check all that apply) Lot q <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> (7r iV S,Yc I Block# <br /> ❑PabliarCa amseve l-Describe Use f a r ts b sr.s�p rN r <br /> ❑City of <br /> El State Owned-Describe Use CSM Number ❑village of <br /> ®Town of G4 fe/lam tie <br /> III.Type of Permit: (Check only one box on Une A. Complete line B if applicable) <br /> A. New System Replacement System Treatmicat/Holding Tank Replacement Only Other Modification m Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Pennit Transferm New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POINTS stem/Com ent/Device: T6eck all that apply) <br /> ,ey Nm-Preamacd In-Ground ❑Prmsueved In-Ground ❑AI-(3rade ❑Momd>2A in.of suitable soil ❑Mound<24 in ofeuiuble soil <br /> ❑Holding Tank ❑OtherDiapenal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispenalfrmatment Ares Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 3�0 . s- goo �o0 9y• o <br /> VI.Tank Ldo Capacity in Total q of Mamd'ecmrer <br /> Gallons Gallons Units <br /> New Twrks Existing Tanks o (i u 4q a <br /> 91: U ti N i+W C7 <br /> Septic er Holding Tmdc <br /> Dosing Chamber <br /> VII.Responsibility Statement-14 the undersigned,assume responsibility for installation ofthe POINTS shown on the attached plana. <br /> Plumber's Name(Print) Plum�ber'.S,ignaturen MP/MPRS Number Business Phone Number <br /> /7 t c. 11'1 /C1 H S /c a.� f�oy� ol�S�s-/ pis- SGG yir7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 760 A/w 3SrvtsSsf� � u/r sT/ 89s <br /> VII Conn /De artinent Use Only <br /> Approved ❑DisapprovedPermit Fee Date Issued lain Signs <br /> ❑Owner Given Ream for Denial $ .3as� o�(� avc�1 (fj '..� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Asach to tompate pans far de system and submit Lathe Comity only an paper not lea than 8 in a 11 Inert In atm <br /> SBD-6398(R.01/07)Valid[tum 01/09 <br />