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commerceml.gov Safety and Buildings Division Comte <br /> 201 W.Washington Ave, ,µr P.O.Box 7162 Stry 0 <br /> sco n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> tiiospartrimanit of Commerce <br /> Sanitary Permit Application Sts eTransaction umber <br /> In accordance with s.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 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,a.15. 1 m,Stab. <br /> I. Applicatiort Information-Please Print All information 8 8 7 9 Se,'6 P✓! I?c P <br /> Property Owner's Name d oWnt/; Parcel <br /> le d's feki SO-SU{( S. ICAFKAaril 9iai oi400 <br /> Property Owner's Mailing Address 11547 Bv/ATW COW'6 Property Location <br /> L y'1 a W. /i 6 f ti Sf. W 6sT-AamR JL (pp f S3 Govt Lot_ /G> <br /> City,State Zip Code Phone Number Yq '/ti Sectio 7 <br /> Tin e V IL. 6e 4f 77 (circle one <br /> IL Type o Building(dteck allthat apply) Lot# T 4 0 N; R__LC- E o <br /> 04 1 or 2 Family Dwelling-Number of Bedrooms A Subdivision Name <br /> Block 1 I IauKo5 a0 6 <br /> 11PublidCommercial-Describe Use <br /> ❑City of <br /> 11 State Owned-Describe Use CSMNumba ❑Village of <br /> Town of ,JAL1CSevl <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System &Replacement System ❑Trisatirsart/Hoklong Tank Replacement only Other Modification to Existing SYatan <br /> (explain) <br /> B. ❑Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Tranfa m New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> W.Type of POWTS S stem/Com ent/Device: Check all that apply) <br /> ONon-Pressurizedln-Ground ❑Pressurizedln-Ground [] At-Grade ❑Mound>24in.ofsueablesoil ❑ Mound<24in.ofauitablesod <br /> ❑Holding Tank ❑Other Dispenal Component(explain) ❑Pb:ft=tment Devin(explain) <br /> V.DispersaIlTreatment Area Wormation: <br /> Design Flow(gpd) Design Soil Applicationpenal Area Required(s1) Dispersal Area Proposed(so System Elevation <br /> 300 , 7 Rale(gpdaf) Dieq )- ? I LY301 S3. 6 <br /> VL Tank Info Capacity in T0 #of Manufacturer ''yy <br /> Gallon Gallon Units <br /> New Troika Existing Tmda <br /> -U4- <br /> Septic <br /> Septic or Holding Tank pp t'�OV <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,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 /> R/�./c o <br /> Plumber's Address(Street, ity,State,Zap Code) <br /> 77 w Y S U/C4tfsr WZ- Se r9-7 <br /> VI;f.Court /De artment Use Only <br /> Approved ❑Disapproved Permit FeeDapte�Isarred Iseu' gait Signs <br /> $ / rN <br /> ❑Owner Given Resaonfm Denial <br /> IX Conditions of Approval/Reasona for Disapproval <br /> Attach to roaplete plan forthe system ad submit to the Cwnty only an paper not less than 8 I x 11 inches id. <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />