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commerce.Wl.gov Safety and Buildings Division coup <br /> 201 W,Washington Ave.,P.O.Box 7162 <br /> FacwZrdanw <br /> s eo n s i n Madison,W1 53707-7162 Sanitary�Permit Number(to be filled in by Co.) <br /> pertmerlt or commerce <br /> Sanitary Permit Application smteTransactionNumber <br /> ith s.Comm.9;:21(2),Wis.Adm.Code,submission of this form to ate approprime govemmentai r Prior to obtaining a sanitary permitNote: Applicationforms for state-owned YOWS are �ll P.�meto the Depamnent of Commerce. personal information Project Address(if different than mailing address) J�J <br /> -Emt accordance with dme Priv you provide may be used for secondary <br /> Lew s.tAll 1 o Stats. <br /> I. A lication Information-Please Print All Information <br /> Property Uwwner's Name <br /> -4'^ 6-,off` <br /> Property Owner's Mailing Address <br /> /U/�b.4� ��� Property I.ocetion <br /> City,State �✓ Zip Code Govt.Lot <br /> r pp Phone Number / <br /> S✓jj / T/ Section <br /> 6�� �'�$ G <br /> II.Type of Building(check all that apply) Lot g T 10 ucle one)-2_N; R / W&.W <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms 4_ Subdivision Name <br /> Block N <br /> ❑PublidCommercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _� _ <br /> ]A, o;NM tem1c� Ys - _Q _ _Ys ORePlaclment S tem ❑Trestment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> Renewal ❑Permit Revision ❑Changeofplumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> piration Owner <br /> . <br /> IV.Tv a of PO v Svstem/Component/Device: Check ail that apply) <br /> ANon-Pressurized In-Ground ❑Pressnriud tGround ❑At-Grade ❑Momu1>24 in.of suitable soil ❑Mound<2q is of suitable soil <br /> ❑Holding Tank ❑Ota Disposal Cmmponent(explain) <br /> ❑Pretreatment Device(explain) <br /> V.Dispersal/TrestmentAraa Informatioe: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area R uircA s <br /> 70 <br /> r rJ 00 (0 Dispersal�00 ed(st) system Elevation <br /> VI.Tank Info <br /> Capacity in Total A of Manufacuuer <br /> Gallons Gallons Units Q <br /> New Tank, Existing Tankr ' C} <br /> ti Holding Tank y w 0 <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))) <br /> �� L /vp ;�Z P'u s anlrc �• MP/MPRS Number Business Phone Number <br /> lumber's Address(Street,Ciry,State,Zip Code) <br /> Am <br /> VIII Count /De artmentUsaOml <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing ext gnature <br /> S Ndy❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovaUReaaons for Disapproval <br /> Atbeh to complek platy for tba ayatem and submit to th<Couary only on paper mt leu than 8 mn x Il iochea im six -, <br /> SBD-6398(R-02/09)Valid thm 02/11 <br />