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commerce.wl.gov Safety and Buildings Division County //�� <br /> iis 201 W.Washington Ave.,P.O.Box 7162 I'3�f n r, /seo n s i n Madison,WI 53707--7162 Sanitary Permit Numb"(o be fd <br /> Department of Commerce led in by C.) <br /> �t��P�� <br /> Sanitary Permit Application ',late'fransacfion Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govermuenml �— <br /> unit is required prior to obtaining a sanitary Permit. Note: Application forms for state-owned POWTS are <br /> submitted In the Department of Commerce. Personal information you provide may be used for secondary Project Address(if different[ban mailing address) <br /> sea in accordance with the Privac Law,s.15.04(l)(m),Slats, <br /> L Application Information-Please Print All Information <br /> Property Owner's Name SsyEa- Sau.sa /G <br /> Parcel q <br /> R 7G� Z G �/ call Powna M+uvHc 3 2 <br /> opeAy owner's Hamlin Address d <br /> Property Lontion <br /> City,State ��)�l Zip Code Phone Number GnvL Lot <br /> InIle-le- G ro )e /n 15-5--311 Y., Y., Section 3 s— <br /> (circle oaeL� <br /> IL 7 pe of Building(check all that apply) �7 Lot q T N; R _E r W <br /> 9-1-or2 Family Dwelling-Number of Bedrooms d9 Subdivision Name <br /> / A 5 ")j �/1)e/'die <br /> � J <br /> 11Blockfl Public/Commercial-Describe Use _ <br /> -._ ___- __— ❑ City of <br /> 11 State Owned-Describe Use CSM Number ❑ Village of <br /> r <br /> — own or <br /> IIL Type of Permit: (Check only one boa on line A. Complete Bne B if applicable) <br /> A. ❑New Stem EA - <br /> 3's 'p-Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0i Renewal ❑Perron Revision ❑ Cb--g--.f List Previous Permit Numbttand Datemaued <br /> Before Expiration g Permit Transfer to New <br /> Owner' <br /> IV.T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> 7ftNon-Preasurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Moonlit<24 in,of suitable sail <br /> ❑ Holding Tank ❑Other Dispersal Component(explain)__ ❑pretreatment Device <br /> V.Dis ersal/Creatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Disp al Area Required(0:1 Dispersal Area Proposed(at) System Elevation <br /> Sod `/may sa f 3. n <br /> VI.Tank Info Capacity in Tom[ got Manufacturer <br /> Gallons Gallons Units ° e <br /> New Tanks Existing Tanks V $ a <br /> C <br /> y3 <br /> Septic a 1k i4V a. <br /> Dosing Chamber <br /> J o <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Riot) Plumber's SignalureMP/MPRS Number Business Phone Number <br /> Plumb <br /> er's Address(Street,City,State,Zip Code) <br /> VIII.Cour /De artin Use On[ <br /> Approved ❑ Disapproved PermmiitCFee ✓J Date Issued Issuing mgnatm <br /> ❑ Owner Given Reason for Denial S X50 /tp�f' '07 <br /> IX.Conditions of Approval/Reasom for Disapproval <br /> Attach to Lomgete plam for the system and wbmlt to the County ordy m paper rot lea thio B ra:11 Inert in sIu <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />