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eommerceml.gov Safety and Buildings Division County J L <br /> 4Uw a 201 W.Washington Ave.,P.O.Box 7162 OCAr n 'e 7-r <br /> i seo n s n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Departmentt of commairce 540 303 <br /> Sanitary Permit Application Stater fion Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental L&iv �—Uie, -r <br /> unit is required prior to obtaining a sanitary permit- Note: Application forms for state-owned POWTS me Project Address( different than mailing address) T <br /> submitted in the Department of Commerce. Personal information you provide may be used for secondary (v <br /> purposes N accordance with the Privacy Law,a.15. 1 m,SWs. / gse ��-yy <br /> I. A Batton Information-Please Print All Information S /Ccs /ZGf 0 <br /> Property Owner's Name n Parcel#07•0Z8-2-40-AP/6- -&AW <br /> Arrield Pekder �a, 3 Od8y// So /do0 <br /> Property Owner's Mailing Address Property location <br /> 43-7-7 Rtndova S>< NE Govt-Lot / <br /> City,State Zip Code Phone Number yy y., Section /S <br /> / <br /> circle one <br /> Al S.5-r!y 9 T NO N; R11f Eo <br /> r� <br /> IL Type of Building(check all that apply) Lot# <br /> qi l or 2 Family Dwelling-Number of Bedrooms 3 ' Subdivision Name <br /> Block# <br /> ❑ <br /> Public/Commercial-Describe Use ❑ City of <br /> D State Owned-Describe Use CSM Number ❑Village of <br /> L/ /,S- P d./Q Town of S4.7-1 <br /> Ill.Type of Permit: (Check only one box on lite A. Complete tine B if appliable) <br /> A. ❑New System pyy��Replacement System D Treement/Hold'mg Tank <br /> Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change ofPlumber ❑Permit Transferto New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS 3 stem/Com ent/Device: Check all that apply) <br /> ®Nen-Pressurized In-Ground ❑Preeauri.W Io-Ground D At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in of suitable soil <br /> D Holding Tank D Other Dispe.al Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ers dIrreatment Ares Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4 . S 900 940 - �' '- <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Unita $$ g a <br /> New Tads Exiting Tanks E u 3 <br /> Septic w HoWing Tank /000 /Oap / S/LAW <br /> Dosing Chamber <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRs Number Bnstness Phone Number <br /> Plumber's Address( trcet,City,State,Zip Code) <br /> 776e7 //w 3S ("7- SH997 <br /> VII sun /De armaent Use Only <br /> Approved ❑Disapproved Permit Fan, Data Issued um <br /> rsued isag it mtum <br /> ❑Owner Given Ressonfor Denial S 3�g <br /> DL Conditions of Approval/Reasoao for Disapproval <br /> Asters to complete plane for tin syste s soil submit to the County only on paper ase lea then 8 in:it Inch.is st. <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />