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f <br /> commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 /? r Pi'e 7� <br /> ` <br /> i sco n s i n Madison,Wl 53707-7162 Sanitary P it Number(to be filled in by Co.) <br /> �emme <br /> partmarrt of corce 4q 49 <br /> Sanitary Permit Application State Trams 'on Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 139217 4- <br /> unit is required prior to obtaining a sanitary p smjL Nom: Application from for stateowned POWTS are project Ad (if diffmeat than mailing address) <br /> 91 <br /> submitted m the Department of Commerce. personal information you provide may be used for secondary <br /> Is accordanm whh the Privacy Law,a.15. 1 m,Stara. .t <br /> I. A Bcatim Information-Phase Print An Informationa. `� 9 O Lakes <br /> Property Owner's Name (� l <br /> Parcell! <br /> i'rR elk l'ra.n k/In 03 Sd1X7— 06600 <br /> Property Owner's Mailing Address <br /> Property 'on <br /> /vc-r .Voerll St• <br /> City,stateGovt.Lot <br /> Zip Code Phone Namber Y., Y., Section_ 7 <br /> y✓1/V Sr3e 3 743_ - (-a7,5` crcleOne) <br /> IL Type of Building(check all that apply) Lot R T ; R /� E CAL19 <br /> IN l or 2 Family Dwelling-Number of Bedrooms subdivision N me <br /> Black p <br /> ❑PubbdCommereisl-Describe Use <br /> ❑City of <br /> ❑Stam Owned-Describe Use CSM Number ❑village of <br /> 1!ary To".f SWI•r',r <br /> IIL Type of Permit: (Check only one box on line A. Complete line B B applicable) <br /> A. ❑New System Q Replacement System ❑Treab,rent/VoNin <br /> g Tank Rephournom Only ❑Otter Modi nation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ChangeofPlumber ❑Permit Transferto New Lint Previous "t Number and Dam Gsud <br /> Before Expiration Owner <br /> Fv. ofPOWTS stem/Com mt/DCA-'. Check all that apply) <br /> ❑Non-Prcesm ed In'Gro ad D preaau cd fr-temand []A4Cxade ❑Mound->24 im of suitable soil IlMound<21inofmitablesoil <br /> INVoiding Tank ❑Other Dispersal Compoamt(explain) ❑pn treatm t Deviu(explain) <br /> V. ' alfrMabuent Ara Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdat) Dispersal Area Required(at) Dispersal Ares Proposed(at) Syefmr Elevation <br /> -3.o e) <br /> VL Tank Info Capacity in TO R of Manteacnrar <br /> Gallon Gallon Units ssp <br /> New Tanks axseng Tanks II U u b p <br /> Septic erRokling lank 733ja- 666 it oes <br /> VIL Responsobility Statement-I,the undersigned,ass raponsibnity for installation of the POWTS shown on the attbed plans, <br /> Plaober's Name(Print) Plumber's Signature Ie1P/MPRS Number Bmineee Phone Number <br /> RI ,�% /�,es /�eaP f� v�ts8r/ -7/s- 36`-vis? <br /> Plumber's Addmss(shut,City,state,Zip Cade) <br /> e2 776p /5/w 3S w2 6S><ee wZ- Se1gS? <br /> VII Corr /De artmmt Use Only <br /> Approved ❑Disapproved Pa'ma Fee Dam)seised Iso ' ent Sigmmrc <br /> ❑Owner Given Reason far Dania) $ 3OV� I� MQ '07 <br /> LK Conditions of Apprw <br /> XbrE, SITE /.�cr6 St�16„GlE. 4t�t Fri A $trf Qbsove�Inq U, <br /> Attachtoeonpkmplam ear aa.ym..mm8.0 mtba coaofy oily as popsy„at teas tbee 9 lrsxttirctaa .I:e <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />