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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 '� <br /> isconsin Madison,WI 53707-7162 Sanitary Permit Num/ber(to befilledinbyCo) <br /> Department of Commerce j T, Lr, i 9 �, <br /> Sanitary Permit Application State Tr saction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental e <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 <br /> purposes in accordance with the privacyLaw,s.15.04 1 m,Stats. / '9 ( P J N G &A <br /> I. Application Information-Please Print All Information -Z5 161 5P V. <br /> Property Owner's Name I /'� Parcel# 0)-Q vo - -/ <br /> Property Owner's Mailing Address Property Location n` <br /> .5— / CJ 0///{7 ' Govt.Lot <br /> City,State Zip(fode Phone Number <br /> q �_'/ Ju(�y., Section <br /> Gr �fS� Gr ltJ� f ySyd �� �9�Zvcleone�` <br /> T�N; R Eo y-) <br /> ��� <br /> It. <br /> '''Type of Building(che all that apply) Lot# <br /> �-rer 2 Family Dwelling-Number of Bedrooms Subdivision Name— <br /> / Block# <br /> ❑Public/Commercial-Describe Use ' <br /> Cl City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑Village of <br /> 111.Type of Permit: (Check only one box on line A. Complete fine B if applicable) — <br /> A. <br /> ❑New System 7-11 <br /> eplacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> �-4�Before Expiration Owner #Jq7JI Q�1AO <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> (((( <br /> 0-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 ersaVTreatment Area Information: <br /> Design Flow Haxh Design Soil Application Rate(gpdsl) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 3c) a 7 y.;2 7 q7, 60 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c c,d 9 <br /> New Tanks Existing Tanks u `e v V m <br /> o � — <br /> 0. <br /> Septic or Bolding Tank 7S0 j6 Gm L <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) /' Plumbqer's Signature MP/MPRS Number Business Phone Number <br /> l� d �/0//'7 �jt/czo� Z2 76 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/De artment Use Onl <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agen I lure <br /> ❑ Owner Given Reason for Denial $151 55 tom}I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />