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commereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 U V <br /> tiDepartimant iseonsin Madison.WI 53707-7162 Sanitary Permit Number(to be fi led in by Co.) <br /> of Commerce Sz 1 Q,j9 I <br /> Sanitary Permit Application State Transaction Number ` � } <br /> In accordance with s.Comm.83.21(2),Wu.Adm.Code,submission of this form to the appropriate governmental NW" <br /> unite mquimd 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 Z43J57 / y `J <br /> purposes in accordance with the PrivacyLaw,a.15.04(1x.),Stats. 7`lo J CO <br /> 1. A licatimInformation-Please Print All lnfom <br /> tation r� <br /> Property Owner's Name Parcel# w <br /> %fa•, Sean /nth �.14 0x0 " 3 oy 300 <br /> Property Owner's Mailing Address Property Location <br /> 7 3.3 3 E of d nd S>' '¢ /O Govt.Lot er a/1W'V X on ZW4 <br /> City,State Zip Code Phone Number 56d Y., Section I/ <br /> 1 Y., <br /> WI(,tii>-e. s 67da6 3/6- 68s- bit-S-f (circle one <br /> IL Type of Building(check a6 that apply) Lot# T 40 N; R /b E o <br /> 2f 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> O Public/Comm uncial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of 0.4 Ae/AHd <br /> 11L Type of Permit: (Check only one boa m lite A. Complete tine B if applicable) <br /> A. ❑New System /u Replacement System O Treatment/Holding Tank Replacement Only O Other Modification m Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision O Change of Plumber O Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/CossipmentlDevice: Check all that apply) <br /> 5t Non-Pressurized In-Ground O Pressurized In-Ground O At-Cade O Mound>24 in.of suitable soil O Mound<24 in.of suitable soil <br /> O Holding Tank O Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispeirsaVrreaftnent Area Infmtnatim: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Disposal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> qS"0 . 5— 1 900 900 96. 93.4-0 <br /> VL Tank hdo Capacity in Total <br /> #of Manufacturer <br /> Gallon Gann Units u $ ,S <br /> Naw Tanks Existing Tanks Y yu b g y <br /> cG :n m y A C7 Zi <br /> Septic or Holding rank <br /> Dosing chamber <br /> VIL Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> �fsGAdd/t /i/o /gars e� artJS't15% 7�S-PGA _4/s'� <br /> Plumber' ress(Stmt, ity,Stale,Zip Code) <br /> 7 /"/W Y 3s tve6Sfe. e'Vz Sof X93 <br /> VII Coun /De artment Use Only <br /> Approved ❑Disapproved Permit <br /> FFas Date stud Issuing ignature <br /> O Owner Given Reason for Denial $ SNI/ e� <br /> D-Conditima of Appr ival/Reasons for Disapproval <br /> Atbeh to ons plete pane for the.ysts.and sabaR laths ConnYy only on Paper not lea than 8 I:ll Inches In she <br /> SBD-6398(R.01/07)Valid d"01/09 <br />