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commerce.wl.gov Safety and Buildings Division County /J <br /> a 201 W.Washington Ave.,P.O.Box 7162 13 ar v)i e T 7� <br /> 'tepwbriefflcnCos i n Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> sari 7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this fora to the appropriate governmental <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)m,Stats. <br /> I. Application Information–Please Print All Informatio <br /> Prope Owner's Name Parcel q <br /> (r f 4,K 4( YS M4 a7-04L Z- -J = 03 <br /> Property Owner's Mailing Address e A <br /> I Property Location 000 - &C <br /> KI <br /> 1330 Sole Ia 70 sit AA ,F <br /> City,State I Zip Code Phone Number S C,J Y., SIC Y., Section 1.S <br /> r r t 1 -511 G10 -71j I (circle one) <br /> LJ <br /> II.Type of Buildi (check all that apply) 0 Lot 4 T �$N; R ) 8 <br /> UI or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block k <br /> ❑Public/Commercial-Describe Use <br /> City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ® Town of u,,b0 i )e1 IhP✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) —0 <br /> A. New System ❑ Replacement ❑ Treatment/Holding Tank Replacement Only HOther Modification to Existing System(explaii <br /> System <br /> B. Permit ❑ Permit Revision ❑ Change of ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV. <br /> !N <br /> e of POWTS S stem/Com onent/Device: Check all that a I <br /> Non-Pessurized In-Ground Pressurized In-Ground At-Grade ❑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 ersal/Treatment Area Information: <br /> Desi n Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 00 . 7 8'S� 90� <br /> VI.Tank Info Capacity in Total k of Manufacturer N z o <br /> Gallons Gallons Units v h <br /> U k H <br /> New Tanks Existing Tanks <br /> _ fi U y vLt 6 <br /> Septic o Helding Tank x (,J (t°ser- <br /> Dos amber ./ 7� /r R ❑ <br /> VII.Responsibility Statement-1,the undersigned,al,sume responsibifil for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(P rn Plum 's Si tore MP/MPRS Number Business P one Nmgpel <br /> Y Z2S22 <br /> PIu tier's Address Street,City,State,Zip Code) <br /> -7 F-(S Ce �� <br /> RJ <br /> VIIJ.County/Department Use Only <br /> Approved _ Disapproved Permit Fee Date Issued Issuing X39teignature <br /> Owner Given Reason for Denial $ -32,5-01' <br /> ra <br /> IX.Conditions of Approval/Reasons for Disapproval c� <br /> ,sys,&- Suva$loin Rltn36 IS 93.13 fah 93.-M <br /> Leri -5 01L-5 aft "' Jlarke 4 k 4pin Atv Sarld. Ah ltA14* taq Rebs aF 0.5 941/M/plty ` &Y Le <br /> rt1wcA ok% vtr(Acs*on of S,tl Tagtv.* - Pwor $o rnSEc{IZ�rm. <br /> Attach to complete plans for the system and submit to the County only on paper out less than 8 1/2 a 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/10 <br />