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corn iterCe.wl.gov Safety and Buildings Division Cowry <br /> 201 W.Washington Ave.,P.O.Box 7162 Ar„ e <br /> 'Wisconsin Madison,W153707-7162 Sanitary <br /> Permit Number(to be filled in by Co.) <br /> Depertmerst or cemtaarae 4 50 <br /> Sanitary Permit Application State Transaction Number <br /> In armrdance with e.Comm.83.21(2),Wis.Adm Code,submission of this form to thea to ovsmmwtal �- <br /> Pt"wri B <br /> unit it required Prior rt obtaining Of s sanitary Person Note: APpbcaou forms fay be <br /> POWTS are project Address(if different than mailing address) <br /> submitted m the Department of Cmnmerce. Personal infomution you provide may be used for secondary // <br /> Purposes in accordance with the Privy Law,s.15.04(1 m,Stats. a.g37.� G0✓G [/G LLeaa <br /> I. A ticatim Wormation-1?kax Print All Information G <br /> Properly()♦rna'9 Name Parcel#07-0Z0•L•s(0 Y&-01' 'O.S•eo¢•OUsoo <br /> otin �aswt(/ 3a��� OHO N3o� 6700 <br /> Properly Owner's Mailing Address <br /> Property Location <br /> 4 l Dere '0001' Gt <br /> Govt Lot <br /> City,State Zip Code Phone Number Ye, Yy Section _ <br /> OSB r"Os•nt 40 Al S4-0 651-)ON- oy R / (circle anew <br /> IL Type of Building(check alt dust apply) ,1 Lot# T O N; _6E m& <br /> I or 2 Family Dwelling-Number of Bedrooms �t Subdivision Name <br /> Block# <br /> ❑Pub&dCossmercial-Dnrnbe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSMNumber ❑Villsgeof <br /> Id Town of 0,4/Z/w no(• <br /> IDL Type of Permit: (Check only one box on line A. Complete tine �yB if applicable) <br /> A. ❑New System �Replacement System ❑TreahoeaVHolding TankReplacemwt Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change ofPlum6a ❑Permit Transfixto New List Previous Permit Numbs and Date Issued <br /> Before Expiration Owner. <br /> IV.Type of POWTS S stem/Com mt/Device: Check all dust apply) <br /> ®Non-Prnsmued In-Ground ❑pressurized Ia-Ground ❑At C—de ❑Xfmmd>24 in.of suitable soil ❑Momd<24 in.of suitable soil <br /> D Holding Tank ❑Otha Dispersal Component(explain) ❑pretreatment Device(cxplam) <br /> V.Di aVPreamtmt Area Wormation: <br /> Design Now(gpd) Design Soil Application Rate(gpdef) Dispersal At"Required <br /> (at) Dispersal Area Proposed(et) system Elevation <br /> W/00 7 �S8 r7-1- 9q•cDOU 6160 /ate,. <br /> VI.Tank Into Capacity in Total #of Manufacturer <br /> GaRom Gallon Units gp $ <br /> New Tacks Fixistirg Tendsall Gp US b w <br /> Septic erliolding Tank X, <br /> Doting Climber <br /> VII.=Will <br /> Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Phi,ber'ss Signature/ // Mp/MpR$Number Baeinne Phone Numbs <br /> arc% �Ta k, tr l�c�hasy /r �SSrs/ 7/s rG6 - `1/,3`7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ) 7764 A. 3f— W-evl o7`r/ 077 <br /> VIIL Comb /De Use Only <br /> ❑Approved ❑Disapproved Permit Fee Date Issued Issuing ignature <br /> / <br /> ❑Owner Given Reason for Denial ,3 d4 0-7 <br /> DL Coriditims of ApprovaMissons for Disapproval <br /> Attach as eaaptete pbn for th ryauss sed submit as the Coady a*an paper ad Ib than 8 yr x 11 haha In ebe <br /> SBD-6398(R.01/07)Valid tion 01/09 <br />