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.wl.gov Safety aad Buildings Division County <br /> n201 W.Washington Ave,P.O.Box 7162 �3"N'h tt.comornerce <br /> nn Madison•WI 53707-7162 Sanitary Permit Nuumber(m be idled in by Co.)rhnent of Commerce <br /> Sanitary Permit Application State//Transaction Number <br /> nc <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental /10 998 5 /\-Jy <br /> mut is required prior to obtaining a Sanitary permit Note: Application forms for state-owned POWTS are Project Address(if diffean rent thmadingaddresS) V <br /> submitted to the Department of Commerce. Persons) information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1 m),Slats. <br /> I. Application Information-Please Print All Information A711 Tol 't✓. Ce Hraer-s L/- I <br /> Property Owner's Name <br /> RrcelM <br /> Joon le P-^ o-r_ oao•,t-yo-/ro or-s er_mos-oa�oa <br /> Property Owner's Mailing Address <br /> Properly Location <br /> 5-39 Lrnh St, Govt Lot_44 <br /> 4�4 <br /> City,State Zip Code Phone Number Yy vy section 33— <br /> Pre.f4o�- W-TSHO at I o T W N: Rib ee) <br /> IL Type of Building(check all that apply) Lot q <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 3 I Subdivision Name <br /> Block 9 <br /> ❑PubliclCommercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSMNumber ///��� ❑Village of <br /> �l . J-3 yr � ®Town of Cs.e/w n <br /> Ill.Type of Permit: (Check only one box on fine A. Complete line BV if applicable) <br /> A. Cb New System ❑Replacement System ❑Treatmeat/Holding 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 Expuation Owner <br /> IV.Type of POWTS stem/Com mVDevice: Check all that apply) <br /> ❑Non-Pressurized InGround ❑Pressurized InGround ❑ M-Grade R Mound>24 ins.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Olher Dispersal Component(explain) ❑Preheatnrent Device(explain) <br /> V.Dispersalfrreatment Area hJormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdat) Dispen.1 Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> `iso /• o vso eis-0 97- el <br /> VL Tank Info Ca dy in Total N of Manufacturer <br /> Gallons Gallons Units <br /> New Tmilrs Existing Tmrks <br /> Septic or Bolding Tank /Do0 /pOe <br /> Dosing Clamber 600 <br /> cep <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown or,the attached plans. <br /> Plumber's Name(Print) I Plumber's Signahue MP/MPRs Number Baseness Phone Number <br /> flit/c 7%/0 k! E-r /a .a � dJs�S7 7<5=f66-vis7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 17 3S WL✓.r s'v 843 <br /> VIII.Cozenty/De artment Use Ord <br /> pproved ❑DisapprovedPer <br /> Reason for Denialmit Fee Date Issued issuing an gnature <br /> s 31 �' ,?3,Ne4 b9 <br /> ❑Owner Given <br /> IX.Conditions of Approval rurasons for Disapproval <br /> AIMeb m complete plum for the system and Submit tothe Candy aay an paper not lea then a in a li Inches in she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />