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corn 17orco,wl.gov Safety and Buildings Division County y <br /> 4t201 W.Washington Ave.,P.O.Box 7162 6CLvn B.ma1 t <br /> i Seo n s i n Madison.WI 53707 7162 Sanitary Permit Number Hn be filled in by Co.) <br /> Department of Commerce 1�1 r <br /> Sanitary Permit Application Slate Transactio/n <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 6"/yNumber <br /> 1,' <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 /> Dees in accordance with the Privacy Law,s.15.04(1)(m),Stats. aEl'd r np!✓ 2?� C46/n '�/ <br /> I. A licotiore Information-Please Print AB Inform ation (76j 9s <br /> Property Owner's Name Parcel d <br /> IYIfc(1ae1 CG /u <br /> PropertyOw/ner's Mailing Address Properly Location (- <br /> Pd' ne�GX �� Govt Lot <br /> City,State Zip Code Phone Number y '/., Section a7 <br /> Web-5I,!, .5-4 r$9& (circle one <br /> It.Type of Building(check all that apply) Lot g T 2/0 N; R/&E o <br /> � lor2 Family Dwelling-Number of Bedrooms of <br /> U I # Subdivision Name <br /> Blookk 11A,4 <br /> (. � n �� ,*K' CC11'&. <br /> ❑PublidCommercial-Describe Use <br /> ❑ Cityof_ <br /> ❑State Owned-Describe Use CSM Number ❑ villageof <br /> Town of C'4k 1A'1 <br /> HE Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System y �Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permi[Renewal El Permit Revision <br /> ❑ Change of Plamber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑ Non-Pressurized 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'Di e ersavrreatment Area Infoation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> — <br /> VI.Tank Info Capacity in Total N of Manufacturer y <br /> Gaaom Gallons Units o $ o <br /> New Tanks Existing Tanks <br /> Septic or Holding Took 3800 3000 ( `j/G�r w <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 /> Ric le //aki"i 24 d�s�si pis- 86G - vis? <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J 77 35- wc4-<71e� wr syg43 <br /> VIII.Count /De artment Use Only <br /> Permit Fee Date Issued Issuln g gesture <br /> Approved ❑Disapproved S -Ir <br /> iQ <br /> ❑Owner Given Reason for Denial \�(/ 8 /Utl <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete phare for the system and submit to the County only an paper net les than 8 in r It Imbes in to <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />