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Commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 ef r n e <br /> y(i se o n s i n Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Departmem of Commerce 53.2.2 0Z <br /> Sanitary Permit Application State Tragsaction Number ( \ <br /> In accordance with s.Comm.83.21(2),Wm Adm.Code,submission of this forth to the appropriate governmental /7,/ /,?a5 <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 ( n <br /> purposes in accordance with the Privacy Law,s. 15.04(Ixm),Stats. )-All <br /> ,/,�/ , /_rr)vC� <br /> 1. Application Information-Please Print All Information `/(i1 >`.K/ <br /> Property Owners Name Parcel# <br /> .`11*PV%044J 4G , c n 43 4 p l y-, 33 o� loco <br /> Property Owner'l Mailing Adthess Property Location <br /> 11 tIS Govt.Lot_113—i— <br /> City.State Zip Code Phone Number y., Section 3 / <br /> Tk, S� 1 4 tT'a?- iS <br /> / ZZ..O -3o23o-3o23 ¢ ucle on <br /> II.Type of Building(check all that apply) Lot# T 3 U N; R E <br /> OQ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> KTown of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. <br /> ❑ New System Replacement 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 /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com nent(Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 18 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 ersalffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> v l 300 300 �� 6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> s U <br /> New Tanks Existing Tanks <br /> m C.f,,,.,bo — e v u v m <br /> 0 2 <br /> at U v, y in �O a <br /> septic Holding Tank <br /> sing amber x �J <br /> VII.Responsibility Statement- 1,the undersigned,qssume responsibility for installation of the POWYS shows on the attached plans. <br /> Plumber's Name(Print) Plum 's Signature MP/MPRS Number Business Phone Number <br /> (S �erfUPK ✓ ZZ 22 <br /> Plumber's Address(Street,City,State,Zip Code) ' <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing en[ 6 ature <br /> ❑ Owner Given Reason for Denial <br /> 751 R5 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 9 In x I I inches in size <br />