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commerceml.gov Safety and Buildings Division County / <br /> seonsin Madison,W1 53707-7162 Sanitary Permit Number(to be 201 W.Washington Ave.,P.O.Box 716216 u f <br /> ifilledinbyCo.) <br /> Department of Commerce <br /> Laorn <br /> Sanitary Permit Application State Tmnsactioh 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 f <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Stats. _ <br /> I. Application Information-Please Print All Information ?,2p v I kt <br /> Pro It Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,Sure Zip Code Phone Number /, %., Section .� 3 <br /> J J 5 C' T L/ N; R (circlE oone) <br /> IL Type o Building(check all that apply) Lot# /_J <br /> '�I or Family Dwelling-Number of Bedrooms 1,2 r r+�% '7 Subdivision Name <br /> p <br /> ❑ Block# C)UL/-IAI-,,)Public/Commercial-Describe Use _ <br /> ' 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of .-} 'qC-L'sc i <br /> 111.Tyryryprre of Permit: (Check only one box on line A. Complete line B if applicable) ' _ <br /> A. New System ❑ Replacement System y p y ❑ Treatment Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber 11 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersabT'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> _3 0 _ y y 4/_5 If q4loo <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> New Tanks <br /> Gallons Gallons Units 0 o v <br /> Existing Tanks �° e V .. <br /> a, c .r3 <br /> i V h N .X <br /> Septic or Holding Tank }-L� ,SC <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ZdAe <br /> F !,�/„, Cc� *sL< � rl � ' 7�71 X59 - 7z8C <br /> Plumber's Address(Street,City,Slow,Zip Code) <br /> e .� S i, e�t� CAJJ 2 <br /> ll.County/Department Use Only <br /> P\Approved I ❑ Disapproved Permit Fee Date Issued Issuin Agent�Signature <br /> ❑Owner Given Reason for Denial s 3x500 1 5_ l _0 , j I I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and sumnit to the County only on paper not less than 8 in x It Inches In size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />