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cOmmerce.wi.gov Safety and Buildings Division County . <br /> 201 W. Washington Ave., P.O.Box 7162 <br /> jf i sco n s i n Madison,W 153707-7162 Sanita Pe t Number(to be filled in by Co) <br /> Deperainierd of Commerce 416 05 <br /> Sanitary Permit Application Slate I mit,aicl on Number <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 samtary permit. Note: Application forms for state-owned POWTS are Project Addre s(if different than mailing address) w <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 xm),Stats. yc� [[ �(J <br /> 1. Application Information—Please Print All Information D ,;bot, L Q) <br /> Property Owners Name Parcel M O'f z-,Z_q/'15'19.4.03'00'e/ Cco I(.\ <br /> Bn. TJ- �.-- 2,1 - ©o V 1 <br /> Propem Owner's Mailing Address J� /� Property Loc ion <br /> / ) J C� Govt.Lot <br /> CiR',State Zip Code Phone Number /tJri�y, SE A, Section <br /> SS6(6 (o <br /> 320 l -336Z -I +''L1 (circle one <br /> Il.Type of Building(check all that apply)I Lot a T 7R_,(,�Ear <br /> �'Alor2 Family Dwelling-Numher of Bedrooms Subdivision N une <br /> Block a <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑Stare Owned-Describe Use CSM Number 333.Uo ❑I pVillage of <br /> Val/ GS,K,p253 W Town of JF. <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> .A. stem New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Mod fiwtion to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision <br /> ❑ Change of Plumber ❑Permit Transfer to New List Previous I emit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> XNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound< 4 in,of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 5U , 7 6 Y3 6-SM 9i.70 <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units v o u <br /> U - <br /> New ranks Existing Tanks �= a = 2 Z $+ m n <br /> a U o7 z; rn u- 0 a <br /> Septic rHolding Tank y j <br /> Dosing Chamber /r / /s <br /> VII. Responsibility Statement- I,the undersigned assume responsibility for installation of the POWTS shown on the att shed plans. <br /> Plumber's Name(Pit I) Plu er's Signature MP/MPRS Numbe Business Phone Number <br /> /�e�S freirr <�' Zz�u� 7rs %6-&Cr <br /> Plumber's Address(Street,City,State,Zip Code) I 1 ` <br /> 7 r (fo c j Vv� tr SY <br /> U.Coun /De artment Use Oilly <br /> Approved ❑ Disapproved Permil'Fee Dale Issued Issuing Age nature <br /> ElOwner Given Reason for Denial S y �5 Z ,. U7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plain for the system and submit to the County only on paper not less than a in x 11 inches in sve <br /> V <br />