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commerceml.gov Safety and Buildings Division County /� <br /> 201 W.Washington Ave.,P.O.Box 7162 N(A v h -i°I <br /> tl,Departmemsconsin Madison.WI 53707-7162 Sanitary Pe mit Numbs (obs filled in by Cu.) <br /> of Cornmeal r,(n <br /> Sanitary Permit Application State Tmna nNumber <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a nationalr <br /> 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 /> ses in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> 1. Application Information-Please Print All lnforanation <br /> Property Owner's Name Parcel# b'7^O <br /> �a.GnP -sw�r�Sorl �.�,� 16-35/-6/hoop <br /> Property Owner's Mailing Address Property Location <br /> (,a 6 S /o wa Z�-. <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> /g /., Section <br /> 1—)&H Atilc) <br /> Y wi 5yff3U T tl I N; R /6(cuclE mi <br /> Type of Building(check all that apply) � Lot# <br /> At or 2 Family Dwelling-Number of Bedrooms W Subdivision Name <br /> Block# NsErls R1 EovW PA��K <br /> ❑Pubko/Commercial-Describe Use <br /> D City of <br /> El State Owned-Describe Use CSM Number a❑y Village of <br /> Y5 Town of -4W I <br /> [IL Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. <br /> D New System .('Replacement System ❑ Treatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> B. ❑Peril Renewal ❑Permit Revision D Change of Plumb" D Peril Transfer to New List Previous Permit Number and Dale hsued <br /> Before Expiration Owner <br /> �I,V/.Type otPOWTS S stem/Com menVDevice: Check all that apply) <br /> X Non-Pressurized In-Ground ❑Pressurized In-Ground D At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dls ersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rme(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 300 <br /> 1 -7 4);) �/al 9ai. CJ <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Unita °' c <br /> New Tatks <br /> Existing;Tanks c�i°. C U -6p b �, A <br /> CGU in W rn 'w C7 0.. <br /> Septic or Holding Tsnk y 0 U <br /> Dosing Clamber V 80(J <br /> VIL Responsibility Statement-I,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 /> /arc-/-e- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VVi�Il.Coon /De arhnent Use Ont <br /> LaJ Approved ❑Disapproved Pemril Fee ( Date Issued Issuing em gnamre <br /> D Owner Given Reason for Denial §3 <br /> IX.Conditions of Appr sd/Reasons for Disapproval <br /> Attach to wmplele plan for the system aM wbmH to the Coumy Duly on paprr est km thin 8 in a 11 inches m size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />