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COmmereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 r r n 2 7Y <br /> isero n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Departmem of commerce C 4D ,3(- <br /> Sanitary Permit Application Stats Tram firm Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate govenunental pus o let t/ <br /> unit is required prior to obtaining a sanitary permit Note: Application fortes for state-owned PDWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary n <br /> Purposes in accordance with the Privacy Law,a.15.04(1)m,Stats. Jt 7 SS 2 i fL �GY <br /> 1. Application Informform <br /> ation-Please Print AN Ins" <br /> Property Owner's Name Pa-cl#o"20-j-t(p-Jfo-33.5 /6-W-Oagwo <br /> /3N t1 16MM'e- 09 Og07S-0 2000 <br /> Property Owner's Mailing Address Property Location <br /> -7p( 5-j 5r Ca leaf /t 1 Govt Lot <br /> City,State Zip Code Phone Number <br /> _ Yy Y., Section 33 <br /> /!7N .SS 33.1 (cyclEo0 <br /> e one <br /> 4 <br /> T NO N; R <br /> IL Type of Budding(dseck all that apply) Lot# <br /> IN l or 2 Family Dwelling-Number of Bedrooms 3 if qL a Subdivision Name ��" <br /> Block#r1 ALwr &ajol aw o D A65 1K <br /> ❑PubadCommercial-Describe Use Os 11 City of <br /> El state Owned-Describe Use CSMNumber El village of <br /> RTownof CA/r/end- <br /> IIL Type of Permit: (Check only one boa nn line A. Complete line B if applicable) <br /> A. ❑ New system y Qr Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑1'emrit Tramfe m New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> 1HNon-Pressurized In-Ground ❑pressurized In-Ground ❑At-Cmde ❑Moond>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Di ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Arra Proposed(at) System Elevation <br /> 4sig 7 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tsnks IirmhngTmks V ggss y3s � <br /> .0 A <br /> Septic or Holding Tank 0�� ✓ <br /> Dosing Charuber <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/Iv1PRS Number Business Phone Number <br /> /Z A/0 k./hs ��.G.�� ��s85I >/s-866-4/r > <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> ,17760 f 3s W-e65r P- rq95R3 <br /> V11L Cow /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Signature <br /> S <br /> ❑Owner Given Reasonfor Denial I 3.254P RMA 2010 6Z.4 6�a�vmm <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plana for the system and submit to the County only an paper not les than 812 a 11 Inches to Are <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />