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commerce.wLgov Safety and Buildings Division Cow <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> {��1 Madison,WI 53707-7162 Sari <br /> MPastma!�nt o,�J � r([o be filled in by Co.) <br /> 4039 <br /> Sanitary Permit Application State <br /> eTTransaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission ofjhis form to the appropriate governmental C.ew e i e <br /> unit is required prior to obtaining a sanitary permit Now ApplkGtion fomes for atateowned 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,a.15. 1 m Stats. <br /> I. A pplicationInformation-PleasePrintAllInformation -?.339J'' <br /> PropeOwner's Name Parcel a <br /> f a q Irt6tA � Z e aa.aal -3 -/S•2%/ o�_emo_n/dca <br /> Property Owner's Maiimg Address Property Location <br /> � �/ .D. tSOX 3rS� <br /> 3395 / X LockNav� X ,293b'� Gov Lot Exc. N//Lz.r <br /> City,Stam Zip Code - Phone Number , <br /> !t `�/ •' 544E /,7f,'/,, Section Zr <br /> �(l.S' ✓7�7/ VZ3'3S/-33 Y' T .f' 0' N; Rcrcleo <br /> II.Type of Building(check all that apply) Lots <br /> E rW <br /> ZIor2Family Dwelling-NumbcrofBedrooma Z Subdivision Name <br /> Block g <br /> ❑ PublidCommerciol-Describe Use - ---- <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number Cl Village of <br /> ,0 Town of 44/'D4z-£rM <br /> M.Type of Permi6 (Check only one box on A. Complete line B if applicable) <br /> A <br /> ❑ New System 1E.Replacsiment System 1-0 TreatmenVIRolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Traafer W New List Previous Permit Number and Dam Issued <br /> BeforC.Fxpl/a60n GwnW <br /> 1%'.T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> >iLNon-Pressunzed In-Ground ❑Pressurimd In-Ground ❑At-Grade ❑Mound>24 in.ofsuitable soil 0 Mound<24 in of suitable soil <br /> 0 Holding Tank 13Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Deign Soil Application Rate(gpds0 Dispersal Area Required(at) D'upersal Area Proposed(sf) System Elevation <br /> 300 7 S,3Z� `f.5-0 <br /> VI.Tank Info Capacity in Total 8 of Manufactwef <br /> Gallons Gallons Units g <br /> Now TWcs Existing Tanks y u A N <br /> p�� <br /> Sep ie or steNrfFed,� <br /> Soo C / <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undt linat Irissurne ponslhility, nstallation ofthe POWTS shown on the attached plans. <br /> PI ftsOnt'l lir & EXCAVATION 14 r' t re MP/M jS Numb9r lines Phone Number <br /> NTY R, <br /> PlumperKI, (a o e)147 <br /> O <br /> VIII.Corn c artment ae nl <br /> Approved ❑Dsa)proved Svmit Fees Date Issued Issum Ag tore <br /> ❑ Owner Given Reason for Denial Q� <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> pli!lolrr <br /> A Eisele to complete plw for the system and submit to the County only on paper not 1w th9 <br /> SBD-6398(R 01/07)Valid thm 01/09 BURN <br /> ZONA <br />