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commereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Su r n e <br /> jf i sco n s i n Madison.WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Departrnern of Commerce 5;z 1 12- <br /> Sanitary Permit Application SaeTransaction Number <br /> a <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govermnental <br /> unit is required prior to obtaining a sanitary 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 /> purposes in accordance with the Privacy Law,a.15.04(1)(m),Slats. /)/J o Ser ver U e. <br /> 1. Application Information-Please Print All Information <br /> property Owner's Namen _µ/- parcel# <br /> /Van //- �roau (.,�,�T 33 O/d - <br /> Property Owner's Mailing Address Property Location <br /> ?,;lS- 3r•o( 19ve E Govt.Lot3Y-3 <br /> City,State Zip Code Phone Number Y., 4/6' '/., Section A 9 <br /> va.ra.n oQ G.i.2' <br /> 5-q 73 6 <br /> circle one <br /> -"pe of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use ❑City of <br /> CSMNumber ❑Village of <br /> El State Owned-Describe Use VaM f. 3 I <br /> Town of <br /> IIL Type of Permit: (Check only one boa on tine A. Complete tine B if applicable) <br /> A. Q New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I <br /> Owner <br /> IV.Ty of POWT$S stem/Com ment/Device: Check all that apply) <br /> 0 Non-pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersalrfmatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sfTJ System Elevation <br /> 2./S-p s- 94 O 900 9/•S/93. of <br /> VI.Tank hdo Capacity in Total #01 Manufacturer <br /> Gaaom Gallons Units <br /> a <br /> New Tanks F`is—Trades $ $ y <br /> Septic or Holding Tank /000 /000 S,[w w <br /> Dosing Chamber <br /> VII.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/NiPRS Number Business Phone Number <br /> A�/G/c /ri/r k/n S I a;/IS'S'S / 1 '7/S: 664tq S7 <br /> Plumber's Address(Sneet,City,State,Zip Code) <br /> o477(0 /5/w y .7S weds {� �vT Svs93 <br /> VIIL Coon /De artment Use Only <br /> O Approved ❑Disapproved Permit Fee Date Issued Issuing Ag Owner <br /> ❑OwnGiven Reason for Denial <br /> $3tl?.OD <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ansch to complete plans for the system and submit to the County only an paper not las than R in r 11 inch.N she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />