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commeme.Wl.gov Safety and Buildings Division County pp <br /> 201 W.Washington Ave.,P.O.Box 7162 V/ AigW- <br /> WD <br /> scon s i n Madison,WI 53707-7162 Sanitary Pe 't Number(m be filled in by—C.) <br /> aparlmard of Consumerist, 43&5-4(o/ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental --1!5-- <br /> unit is required prior to obtaining a sanitary permit. Note: Application forme for state-owned POWTS are Project Add ss(ifdifferent than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15.04 1 m,Stats. <br /> I. Application Information-Please Print All Information -<�^C OJT; <br /> Property Owner's Name Parcel# <br /> Dots LLOL 19,4e �, 3a o37-- 4Z5- o3 soo <br /> Property Owner's Mailing Address Property Location <br /> GaYt.Lot/ W y Section <br /> City,State Zip Code Phone Number �1(� <br /> 10SeMLA 14/1 5-102D -715-Z94-3712T i' R _7(circle one <br /> H.Type of Building(check all that apply) Lot# <br /> E o <br /> Wj or 2 Family Dwelling-Number of Bedrooms I Subdivision [me <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village o <br /> Vbt 12 P6 150 14own of -3055 <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> `k' ❑New System Replacement System ❑Treatme utHolding Tank Replacement Only ❑Other Mod ification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous -torn Number and Date Issued <br /> Before Expiration Owner <br /> IV. <br /> a of POWTS S stemlCom onent/Device: Check all that apply) <br /> ts <br /> sgNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound< 4 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑pmorartment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Ap lication Ra 1) Dis emal Area Required(at) Dispersal Area Proposed(s System Elevation <br /> AS( ,6 C�us1u� 5�3/F.z -M ..6 X50 102. 7Z -4- /01,42 <br /> VI.Tank Info Capacity in Total #of Manufacturer m <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks <br /> 0 <br /> aU <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility Foll installation of the POWTS all the a ched plane. <br /> Plumber's Name(Print) APlumber'sre Business Phone Nmnber <br /> AFF �X 223Z9Z '715=1S5 - 294W <br /> Plumber's Address(Street,City,State,Zip CadBOX 56S h// 5 9009 <br /> VM-CountylDepartment Use Only <br /> Approved ❑Disapproved -/Fyee ''rJ �Issmd <br /> Issuin gen gnature <br /> ❑Owner Given Reason:ffoirDeaia1 --1)t1V j 7 <br /> DL Conditions of Approval/Reasons for Disapproval <br /> r -11)6r— <br /> Atimets to complete plane for the system and submit to the County only on paper not less than8 in r It Inches in alae <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />