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eommereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 6"lo n el <br /> jf i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application Stat.Transact on f^u�mber I R <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Nyz nCUI(.1.j v <br /> unit is required prior to obtaining a sanitary permit. Note: Application foams for state-owned POWTS are Project Address(ifdifferent than madingaddr..a) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Q / � <br /> I. Application Information-Please Print All Wormation T G. Ads$ al<iC LLIA <br /> Property Owner's Name Parcel#07 a I G-A-If 0-17­13•r <br /> K4�tn Anol-ceso � 3 57R05-4904t - O>4o00 <br /> Property Owner's Mailing Address Property Location .S /Io' o f <br /> t 81/OJ E• /34ss Lk Aeof. Govt.Lot If t L.YI%4 W of 12oai( <br /> City,State/ fiZip Code Phone Number y,, %, Section 137 <br /> Do'r aa tN- Sy .)0 (cycle one <br /> T HO N; R17 Ea <br /> b <br /> II.Type of Building(check all that apply) Lot# <br /> kj l or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> 0 Public/Coni nercial-Describe Use <br /> ❑ Cityof <br /> 0 State Owned-Describe Use CSM Number 0 village of <br /> Town of tl.N t O H <br /> IIL Type of Permit: (Check only one box on fine A. Complete fine B if applicable) o_ _ <br /> A' 0 New System y �Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Mod cation to Existing System(explain) <br /> B. ❑Pertnil Renewal ❑Permit Revision <br /> ❑ Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check a6 that apply) <br /> Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<yt in,of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explaird ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treabnent Area Information: - <br /> Design Flow(gpd) Design Soil Application Rate(gpdaI) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> VI.Tank Wo Capacity in Total #of mmaachu <br /> Gallons Gallons Units y o'$ v <br /> New Tanks Existing Tanks w e -o ° u y w m <br /> 0 <br /> tC U m A rn W C7 P. <br /> Septicer Holding Tank <br /> Iti '�trsfe�- X <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) / Plumber's SignatureMP/MFRS Number Business Ph Number <br /> 2/r�G Na /Ctrs /< p�S>Ts'i �s 6 -4O.4 - 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 70 o #.Z <br /> rlV�IIIIL Coun /De artment Use Only <br /> yApproved ❑Disapproved Permit Fee Date <br /> 0J� DDate��J Issued Issuing Agent <br /> O Owner Given Reason for Denial S�o2Gy Ao ,2ri l' <br /> IX.Conditions of ApprmaUReasons for Disapproval <br /> D C 8Y <br /> "Ill . 0 A .... nn <br /> Attach to compete plansfor the system and submit tothe County any an paper ntt lea a 11IrcMa <br /> SURN1 i iUU <br /> ll <br /> SBD-6398(R.01/07)Valid thru 01/09 C <br /> �.1�i <br />