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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 21 n l !f <br /> iseonsin Madison'WI 53707-7162 Sanitary Pe <br /> rm t Number(to be filled in by Co.) <br /> Departmnrst of C,,mmeroC!e 4 5(>7 <br /> Sanitary Permit Application Shte Transact on Nmober <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 forms for stakowned POWTS ase Project Addre a(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 PrivacyLaw,a.15. 1 m),Stats. k O ey �e'e L�a 12X <br /> L Application Information-Please Print AB htformation <br /> Property Owner's Name Parcel 8 <br /> Al;te-e .Jae o� <br /> Property Owner's Mailing Address Property .m <br /> IS 4 o Ce /Ca /9 Govt Lot <br /> City,Stale Zip Code Phone Number S w y, s!/V., Section'_ <br /> s sOM f✓ /�� S'df do/ 7/.>r `,7S-Y�o� (cock one <br /> T 4 O R.L.,1 OrW <br /> IL Type of Building(check all that apply) Lot N <br /> Q1 1 m 2 Family Dwelling-Number of Bedrooms 3 Subdivisionams <br /> Block 8 <br /> D Public/Commercial-Describe Use ❑City of <br /> — <br /> State Owned-Describe Use CSM Number ,❑Village of <br /> V I pTown of <br /> a l�J <br /> ry <br /> III.Type of Permit- (Check only one box on Ihne A. Complete line B if app viable) <br /> A. ry New System ❑Repineement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Mod ification to Existing System(explain) <br /> B. ❑Permit Renewal D Permit Revision D ChangeofPlumber DPemrt Tramferm New List Previous 't Number and Date Issued <br /> Before Expiration I I Owner <br /> IV.Type of POWTS stem/Com enf/Device: Check all that apply) <br /> bi Non-Pressurized In-Ground ❑Prusluized In-Gmund ❑At-Grade D Mound>2A in.of suitablesoil ❑Mamd< is of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreamrmt Device(explain <br /> V.Disiamadfrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf System Elevation <br /> 4 . 7 (W 4F;? 1 GY8 43. 0 <br /> VL Tank Info Capacity in Total Units Nt Manufacturer <br /> Gallon Galloon <br /> New Tanks Existing Tales g $ d m <br /> V rn o y h.V M <br /> Sepnc or HoWnng Trek /000 /BOO <br /> Dosing Clamber <br /> VII.Rdponsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on theat ached plans. <br /> Phom�bcea Name(Print) Plumber's Signature <br /> WIMFRS Nu Business,Phos Number <br /> IGlGlc ?O le-,- j Ot/'✓r Q.f/ 7/.f=QGni- r/�S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> et 776 0 3.f U/eb.l?I r wi s Y X77 <br /> L County/Department Use Only <br /> meed ❑Disapproved <br /> Permit <br /> rfU <br /> FF�e7e� �^�-� Daft Issued Issuiag Signature <br /> ❑Owner Given Reason for Denial S aJ -W -a7-07 <br /> DL Conditions of Appruval/Res sore for Disapproval <br /> Attach mcamplans plan far the sysreased=bank to the County only ou paper not has than 8 l 111 in metre <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />