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commerce l.gov Safety and Buildings Division County <br /> /tom y 201 W.Washington Ave.,P.O.Box 7162 <br /> t sconsi ■ Madison,WI 53 707-7 1 62 Sanitary Permit Number(to be filled in by Co.) <br /> It, of Commerce ` b <br /> -521 <br /> Sanitary Permit Application State Transaction Number i <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 <br /> purposes in accordance with the Privacy Law,s.15. 1 m Stats. <br /> L Application Information-Please Print All Information hU y 7 Yr .; pjf( <br /> Property Owner's Name Parcel# <br /> A✓; Al3 � G <br /> Property Owner's Mailing Address Property Location <br /> S <br /> ���� W Gov[.Lot <br /> City,bodeP �rs\I Zip Code Phone <br /> Phone Number /. Section 2-7 <br /> C \ 1 V� V ���JIJ �(J -11 <br /> O ' dcircle on <br /> k.R1 Ea� <br /> S�IIa,.Type of Building(check all that apply) Lot# <br /> 41 or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name <br /> Block# <br /> D Public/Commercial-Describe Use <br /> ❑City of <br /> D State Owned-Describe Use CSM Number D Village of <br /> 1,Town of M e-e yl 0 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y El Replacement System ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal D Permit Revision ❑Change ofPlumber D Pemtit Transterto New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Typc of POWTS System/Component/Device: Check all that apply) <br /> 1.Non-Pressurized In-Ground D Pressurized N-Ground D At-Grade D Mound>24 in.ofsuiable soil D Mound<24 in of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dir ersaVlYeatment Area Information: <br /> Design Flow(gpd) Design Soil Ap lication liate(gpdsl) Dispersal Area Required(sl) Dispersal Area Propos (sQ System Elevation <br /> 3aC 42 � w35 y `111& <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks `v V •- - <br /> w <br /> Sepuc or Holdiag'fmk <br /> 11 <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(Print) Plumber's ignamre MP/MPRS Number Business Phone Number <br /> '�v l 745- n-c 734>s' <br /> Plumber's Address IS .C' State,Ziji Code) <br /> W I � (-t 01 GU, s,� F 75 <br /> VIII.Corn /De artment Use Only <br /> (Approved D Disapproved Permit Fee Date Issued - Issuing Age e <br /> 300 <br /> s 0 <br /> ❑ Owner Given Reason for Denial 5 04, <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach in complete plans for the system and submit to the County only on paper not less than 8 In x l i taches in size <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />