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commerceml.gov Safety and Buildings Division County . <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Iscon3In Madison,W153707-7162 Sanitary Permit Number(to be tilled in by Co.) <br /> Delaertment of Commerce 551243 <br /> Sanitary Permit Application State Transaction Number ( }� <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to me appropriate governmental 2C>Z 0 5 9 9 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing addre s) —L— <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 3-5 / n <br /> purposes in accordance with the Privacy Law,s. 15.04(l m Stats. 30 76 p 7 N v <br /> 1. Application Information-Please Print All Information J <br /> Property Owner's Name //�� Parcel N o 7-O <br /> �r701 -000 <br /> S rale. (/ J�� 01 -000 , 0/3-/00 <br /> Property Owners Mailing Address Property Location <br /> ,5D2 .5oc-14 Govt.Lot <br /> City,State Zip Code Phone Number i{1L 1A IVL-.' A Section <br /> Prnccz-16 n A44 SS371 -7/9-556 6355 (circle one) <br /> It.Type of Building(check hl that apply) Lot is T�_N; R� E or W <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms3 Subdivision Name <br /> ( � Block d <br /> Public/Commercial-Describe Use b <br /> ❑ City of <br /> C1 State Owned-Describe Use _ CSM Number ,'" ❑ Village of <br /> 1'o/ 2t� <br /> 111.Type of Permit: (Check only one box online A. C-amplete line B if applicable) <br /> A' New System ❑ Replacement System ❑ TratmentrHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration i Orme, <br /> IV.Type of POWTS System/Component/Device: (Clieck at!that apply) 1 <br /> -AIon-Pressurized In-Ground ❑ Pressurized In,Ground ❑At-Cradc ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil li <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/rreatioent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y 1X14© 2- V.0 I r13. s---.o <br /> VL Tank Info Capacity in Total a of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks pv9 e V <br /> 6U tiV n, <br /> Septic or Holding Tank 7 S O 7 J�U <br /> I f-v l e <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assum;itresponsubility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name )n(Print)'` Plumber's gr re MP/MPRS Number Business Phone Number <br /> J,tt-, 14 f 213 »t 7 r 376 17,P <br /> Plumber's Address(Street,City,State,Zip Code) <br /> to . .✓ L-.0 x 8 2 7 <br /> Will.County/Department Use Only <br /> ( 'Approved ❑ Disapproved Permit Fee Date Issued Issuing en gnature <br /> ❑Owner Given Reason for Denial ;c,a..r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D EcEmrn <br /> Attach to complete plans Aar the system and submit to the County only oa paper not less Aran 8 rlx x 11 Inch <br /> SBD-6398(R.01/07)Valid thru 01/09 f3URNEIT COUNTY <br /> ZONING <br />