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C0mrnerce.WI.g0V Safety and Buildings Division <br /> County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> isconsin Madison,W1 53707-7162 13CA rpt <br /> Departmgn(of Commerce Sanitary Permit Number(I be filled in by Co.) <br /> 153,2 /z 8 <br /> Sanitary Permit Application Stam Transaction Number <br /> In accerdance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior m obtaining a sanitary permit Note: Application forma fm state owned POWTS are /�(Jt pry 1 A I <br /> submitted to the Depanee with <br /> the <br /> p Commerce. .persoart information you provide nay he used for eecondary Prolecl Address(if different than nailing address) <br /> sn in accordance wah the prig Law,e. Sfafs. <br /> L A <br /> uses OR Wormation-Pleax Print All lnforrtatio <br /> Property Owner's Name es Ir 7 ted `C. <br /> Ina r k OU le tzParcel# <br /> Property owner's Herding Address ' O O D <br /> 7!/O wCSf /lath Prop"Location <br /> City,State Govt Lot <br /> Zip Cade Phone Number <br /> /y/6d,arra, /pet /Y/A/ SS'N3e Yy '/., Section /0' <br /> IL Type of ing(check M that apply) T y0 (ricks ory <br /> 19 y, PP Y) / Lot N; R_/�Eor(R�' <br /> 1 or 2 Family Dwelling—Number ofBedrooms /p <br /> Subdivision Name <br /> 0 Public'Commereial—Describe Use Block# / fit. /) P <br /> "e( IRdYr �Y C P.i 1Ntp <br /> 0 City of <br /> 0 Stam Owned—Describe Uae CSM Number <br /> ❑Village of <br /> S <br /> Town of ca lC/.t n d• <br /> IIL Tyupye Nof Permit: (Check only orre bos on lute A. Complete tine B if appticabk) <br /> A. 19 ew tem —C) <br /> ri 0 Replacement System ❑Treatmmt/Hokhng Tank Replacemmt only ❑OtherModification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Pmnit Revision <br /> Before Expiration 0 Chang=Pl—b- ❑PCrI I Transfer m New 'an Previous Permit Number and Dam Issued <br /> IV.T of POWTS 3 stem/Com wren Owner <br /> t/Device: Check all that s <br /> roma ❑Prcsn <br /> sriudln-Gmrmd ❑A[-Grade <br /> ❑Mound>24 mn.ofeurtabb soil ❑Mound<24 in. <br /> ®Non-pre" ed In-" <br /> ofsuitablesoil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) <br /> ❑Pretreatment Devices(explain) <br /> V• rsaVfrahnent Area lnformatitn: <br /> Design Flow(gpd) Design Soil Application Rate( <br /> /SO BPdaD Dupereal Ara Requrced(sf) Dispersal Area Pro <br /> '� �! � posed(af) System Elevation <br /> VL Tank Wo "parity,in / 4, 9a. yp <br /> Total #of Mam oacmrer <br /> Gallon Gallon Unin V <br /> New Tanks Brdsring Tanks $ <br /> Septic or Holding I.* 8 5 <br /> y ee y <br /> Dosing Clamber O SOO / S/eta ✓ ii c7 <br /> VIL Itespontibitity Statement-1,the undersigned,assume responsibility for mnstallation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) <br /> n Plumber's Signature MP/MPRS Number <br /> /</ek /t/ePkin s ' , A ,/� Business Ptrmre Nnmher <br /> Plumber's Ad---.,---,City,Stam,ZIP Code) ��SSS / '7/6-- Vd;(, — [//5--7 <br /> e17760 (/tin Lvcbs�r toll Syarg3 <br /> VIIL Cour /De rtrtotent Ux Onl <br /> APProved 0 Disapproved Permit Fm Date Issued Issum <br /> S c 8 Signlure <br /> 0OwnerGivenReasonforDermal <br /> 17G Conditions of Appro sazjc, sons tar Disapproval <br /> Atfaeh m ronpleh plan(or the syafea and subea b the Com <br /> ssY an1Y m PPar root ha thm a trz:lt hales b elu <br /> SBD-6398(R.01/07)Valid thru 01/09 ' <br />