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JbIbb commeree.Wi.gOV Safety and Buildings Division County <br /> WI e 201 W.Washington Ave.,P.O.Box 7162 Qk rn*4� <br /> f i seo n s i n Madison,WI 53707-7162 SanitaryPermit Number(to be filled in by Co.) <br /> �epartmern of commerce 4–c) <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental & <br /> unit is required prior to obtaining a sanitary permit Note: Application forma for stat"wned POWTS are Project Address(if different flan mailing address) <br /> submitted to are Department of Commerce. Personal information you provide may be used for secondary <br /> purposesin accordance with the Privacy Law,a.15. 1 m,Stats. Ste{/n r< Tr ret <br /> L A m <br /> Application Information-Please Print All hrfonnation Sh y <br /> Property Owner's Name Parcel# O/L S7 0LI;00 <br /> ,s"Ir Ase k Mn 07-012-2-40-15-09-5 <br /> Property Owner's Mailing Address Property Location <br /> 38'668 Hem"'q Gir. <br /> Ci State Govt Lot <br /> city, Zip Code Phone Number Yy of Yy Section <br /> Noel-A /3eA.r-A A"A✓ ss•rG-S !oS/- 4e� - 4df7 T [�� N; R /S�Eoe(D <br /> IL Type of Building(check a6 that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms /( S6 Subdivision Name <br /> Block# SETT1s)& s <br /> ❑Pu6lidCommercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of JA c ks s n <br /> 1I1 Type of Permit: (Check only one box on line A. Complete tine B if applinble) <br /> A. New System ❑ <br /> ye Replacement System ❑Treatrnmt/lIolding Tack Replacement Only ❑Other Modification to Existing System(explain) <br /> B. Permit Rerwwal ❑Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWTS S stem/Com onenVMvice: Check aH that apply) <br /> R Non-PreMmu(I InGrund ❑Ressurized In-Ground ❑At-Gmde ❑Mound?2A in.of suitable soil ❑Mord c 2A in of suitable soil <br /> ❑Holding Tank ❑OthcrDispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DisismaWreaftnent Area Wormation: <br /> Design Flow(&pit) Design Soil Application Rate(gpdsf) Dispersal Area Required(af) Dispersal Area Proposed(sf) System Elevation <br /> 300 , S Eco Goo gy.s <br /> V1.Tank hdo Capacity in Total I #of Manufacturer <br /> Gallons Gallon Units <br /> e <br /> New TanksU u <br /> w <br /> FxaMg Tanks dr U y y w C97 Z>•. <br /> Septic or Holding Tsnk goo <br /> 8O0 SKAs✓ <br /> Deans Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> /zrc.e No /<:o l I?.t1....P� lr�S Ss� 7is_�6�- �/�s-7 <br /> Plumbers Address(Sweet,City,State,Zip Code) <br /> ,!7760 /mow 3U-- <br /> III. <br /> SIII.Cam /De artment Use Only <br /> Approved ❑Disapproved Permitl7cce Date Issued Issuing turn <br /> ❑OwnerGiv®Reason for Denial §" C /L —A <br /> DL Condition of Approval/Reason far Disapproval <br /> Nmch U compete ptamfor the syst=aW=bmh to the County only m paper rot kn thm$in l ll iocbm hon ala <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />