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R1efCe.w1.90V Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> tio-Lonc s i nF Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ommerce 53z"' <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with$.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Ou'li y /vGtlwAj <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if diffmcm 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. Ixm),Stats. L <br /> I. Application Information-Please Print All Infiurraittion � 760 w �-f <br /> Property Owner's Name n Parcel# <br /> l� my <br /> 7of oil Ha/bd 9409 o00 -v/coon <br /> . eve ri ,rot G-e7'%�"S �v ! r4329 0410) <br /> Property Owner's Mailing Addreeaoperty Laption r <br /> 7(0�� �� Ipo/ 3S 5 /6D' of l: Z73 <br /> sew:ixe <br /> City,State Zip Code Phone Number SF JYy $)=Yy Section <br /> IL Type of Building(check all that apply) e� Lot# T �N; R 1b E or W <br /> l or 2 Family Dwelling-Number of Bedrooms J Subdivision Name <br /> Block# <br /> ❑Public/Commeroial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Deernbe Use CSM Number �❑ Village of <br /> igp Towo of Oct/G/., <br /> IIL Type of Permit: (Check only one boa m1 fine A. Complete tine B B applicable) <br /> A. ❑New System laccment System Treaamcm/Holding Tank <br /> Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ e of Plumber List Previous Permit Number and Date issued <br /> Chang ❑Permit Transfer m New <br /> Before Expiration Owner <br /> IV.Type of POWTS tem/Com ent/Device: Check sU tbat a <br /> ANon-Pressurized In-Ground ❑Pressurized ia-Ground ❑ At-Grade ❑Mound>24 of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersalfrreatinciat Area lnformatlma: <br /> Design Flow(gpd) Design Soil ApplicationRate(gpdef) Dupasal Area Required(et) Dispersal Area Proposed(at) S}refan Elevation <br /> y f'D /v `/-7 l v f Spd `/0 <br /> VL Tank WO Capacity in Tot" #of Manufacturer <br /> Gallons Gallons Unite yy o <br /> New Tanks Existmg TanksFF�ii b] <br /> 3 <br /> 'n W rn Gi.C7 � <br /> Septic or Holding Tank /ddb <br /> Doaug Clmmher <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SSignaturee MP/MPRS Number Business Phone Number <br /> 7z/e'e /TO /G iNl /*ia -rze-� J7` �DI,��SJ — Se/S <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ot 7 7400 "�91h �S- �✓�%sfY� w f S�/a5 �� <br /> V IL Court /De artmrnt Use Onl <br /> io Approved ❑Disapproved Permiit Fee Date Issued 2p Issuing ignsbrre <br /> ❑Owner Given Reason for Denial 8 325 ( aw�7 A10 \ <br /> LY.Conditians of ApprovaVRemc ms far Disapproval <br /> Attarb to complete phnsfar the ripen and mbmb to the Courcy duly an paper rat leas than 814 x 11 inches h sbs <br /> SBD-6398(R.01/07)Valid than 01/09 <br />