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commetcem.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 U0-/0 Com-. <br /> tiilDepartnuentsconsin Madison,W153707-7162 Sanitary PermitNumber(tobefilledinbyCo.) <br /> of Commerce <br /> Sanitary Permit Application StateTa on Namber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application force 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,s.15.04 1 m,Stars. _ <br /> I. Application Information-Please Print All Information ' -�2 5- <br /> Property Owner's arcs Parcel# <br /> G ( 0- -41 35D 07-0Q-z• 54',5- <br /> Property <br /> •I -Property Owne'r's Mailing Address / - p 1 Property Location <br /> I-) O ne �:2 �z z +Z.� �. C (� '�-T I\U Govt.Lot <br /> City,State <br /> ��tt Zip Code hone Number y,, Y., Section � 5 <br /> ,rl(� S �i( W �L L[JO 6Q9-�jQQ -iO (circle one <br /> 11.Type of Building(check that apply) 7?Q / Lot# :/ T��N; R E or QW <br /> Tor 2 Family Dwelling-Number of Bedrooms J e Subdivision Name <br /> I Block# <br /> ❑Public/Commercial-Describe Use I <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number qq❑Village of <br /> GSm_/i 1 P 130 7"oam of CJ on d .,j a,- <br /> In.Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> A.. ❑New System 31te lacement System Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ) <br /> ❑Change of Plumber List Previous Permit Number and Date Issued <br /> B. 13 Permit Renewal El Permit Revision El Transfer[o New <br /> Before Expiration Owner '912.2 7 /3 /O <br /> IV.Type of POWTS System/Compo ent(Device: Check all that apply) <br /> yq lVon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound a 24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> /❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �a , 7 &'e5/3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o$ <br /> New Tanks Existing Tanks d c 2 .uo. � is <br /> a.V in h h C7 a <br /> Septic or Ho,xy_Te„k- pup C.—. <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Na a(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Na <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,Q o _ 5_I5/ Si, ' tf, A) <br /> VIII.County/Department Use Only <br /> 5f Approved ❑Disapproved Permit Fee Date Issued Issuing Agent core <br /> ❑Owner Given Reason for Denial S32r� v /tf vw N <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> r�tE: 7tv3 Pevm,f lfieS t-v dov,hys Ffa. £H.e of 'E - <br /> Anach to complete plans for the system and submit to the County only on paper not lees than 8 IR a 11 Inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />