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i <br /> I <br /> eommerceml.gov Safety and Buildings Division County <br /> Abis 201 W.Washington Ave.,P.O.Box 7162 - &,.n-e <br /> iseonsin Madison,W153707-7162 Sanitary Per it Numb"(to be filled in by Co.) <br /> Department rN Commerce 141, 48a <br /> Sanitary Permit Application State Tran tion Number <br /> In,accordance with a.Comm.83.21(2),Wis.Adm.Coda,submission of this Form to the appropriate governmental -z'- <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Add cia(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> Eurpose,in accordance with the Privacy Law,s.15. 1 m,Stats. <br /> 1. Applictitioninformation-PleasePrintABWormation <br /> Property Ownw's Name —J1-�'- /� Parcel# <br /> Mtri/yN Sea/'t ctz 6.r �I dal. 4/302 0]/a0 <br /> Property Owner's Mailing Address Property Lo atim <br /> -7//0 G 6/rte 12Y. GovL Lot <br /> City,State Zip Code Phone Number SE y,, 01 <br /> 1 <br /> St✓ Y Section Y <br /> Wedste✓ w � S°/893 7�5 866- <br /> 7,5 08 r 4-10 ; R 16(cncE ons) <br /> vffl <br /> IL Type of Building(check all that apply) /J Lot# <br /> 1 or 2 Family Dwelling-Number of Bedroom% % Subdivision 11arns, <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State owned-Describe Use CSM Number ❑Village o <br /> Town of O/C-1.6r b0 <br /> IIL Type of Permit: (Check only one box m lime A. Complete Bne B if apptinble) <br /> A. ❑New S siert <br /> y �Replacement System ❑Treamrnf/HoWing TankReplacemrnt Only ❑ Other Ado lification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ChangeofPlrmber ❑PemLLTranfcrto New List previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> TV.Type of POWTS stem/Com mrnt/Device: Check all that apply) <br /> J9Non-Preunized In-Ground ❑PrCilalr ed lii•Groand ❑At-Conde ❑Momd>2A in.of suitable soil ❑Mond 14im of suitable soil <br /> ❑Holding Tank ❑lhherDispersal Component(explain) ❑PretreamemDcvice(explain <br /> V Halment Area Information: <br /> Derigti Flow(gpd) Design Soil Application Rste(gpdat) Dispersal Ares Requved(af) Dispersal Am Proposed(81 System Elevation <br /> as <br /> . .5— / 0 1 /'Aae g,t , ' <br /> VI.Tank Info Capacity in TOW #of Manufacturer <br /> Gallon Gallons Unita c 9 U <br /> New Tanks Existing Tarks 'ag' <br /> Q4- <br /> Septic <br /> Septic or Holding Trod` <br /> Damg Char. S-0 O <br /> / <br /> VIL Responsibility Statement-L the undersigned,assume respunsibitity for installation of the POWTS shown on the al ached plans <br /> Plumber's Name(Print) Plumber'aa Signature 1/ MP/MFRS Numb Bninen Phone Number <br /> 2/ek /L/�a /Cr„ s /`- . ' f-8s / 7rs= 9e4 - v.s-7 <br /> Plumber's Address( beret,City,State,Zip Code) <br /> 776d //a. 3.5-- tdeysfr✓ Gt/i� x`/893 <br /> rV�.I�IL Coun /De artment Use Only <br /> C Approved ❑Disapproved Permit Fee DaDateI,IssuedIssuing S, fine <br /> ❑Owner Given Reason for Denial S ?50/7 Iu"lpl�) 0-] <br /> IX.Conditionrvl/Re <br /> s of Apprtamom for Disapproval <br /> AWehbmmplkpiamfortberiAeumdmbmittotbeCoureymdympapeemtkssdmglaxllioe insist <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />