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commeree.wi.gov Safety and Buildings Division tSanitary <br /> unty <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> tiepartmentsoonsin Madison,W 153707 7162 Permit Number(to be filled in by Co) <br /> of Commence S <br /> -- lT action NuSanitary Permit ApplicationrIn accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate governmenta _ _unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS aroject Address(if d7ffcrent than mailing address) ` <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary � ye}�l <br /> purposes in accordance with the Privacy Law,s.15.04(1m),Stals. —_ G11#0 A i <br /> L Application Information-Please Print All Information _- -- <br /> Property Owner's Name Parcel k 07- <br /> J <br /> Property Owner's Mailing Address Property Location <br /> O (--1 �kc J -- _ -, Govt.Lot_ <br /> City,State ZIp Code Phone Number y, 14" Section <br /> .1.� e vele one) <br /> er/n oaks M nJ SS/�7 - T 17CN; R /s�`_Fm® <br /> - -- <br /> ---- � ---- lot# <br /> 11.Type of Building(check all that apply) C/ — -- -------- <br /> ��,(( / Ss�odrvumn Name <br /> I(fTor2 Family Dwelling-Numhcr of Bedrooms,-_ —_ <br /> — _ <br /> Aleck N _ <br /> ❑Public/Commercial-Describe Use <br /> ,_-------_______..._--- -. ❑ City of_—�-_ - <br /> CSM Number ❑ Village of ..- <br /> ❑State Owned- Describe Use_.-_..__ ----- --- --- Towner ,�,ff � / zzL <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System replacement System ❑Tremment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> -- List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of Plumbcr ❑Permit'fmnste,to Ncw <br /> Before Expiration Owner <br /> IV Type of POWTSSystem/Component/Device:. Check all thata 1 _.____—___—.— ----- -------- — --- - ----Pp y-- <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>,24 inof suitable soil ❑ Mound<24 in of suitable sod <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) - ❑Pretreatment Device(explain)_ <br /> V.Dis ersal/Treatment Area Information: ---- - �� <br /> Design Flow(gid) Design Soil Application Ratei gpdsf) Dispersal Arca Required(----Fit ispersal Arca Proposed(sl STY, <br /> 3 0 _.�— ��o yS Sb <br /> --V1.'rank Info Capacity in Total Sof Manutacnocr o <br /> o <br /> Gallons Gallons Units U C <br /> Ncw tanks lixi.ming looks — co o v v in m <br /> a U ri v. <br /> Septic or IfeMieg.]ank 7S� 7S0 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW Ts shown on the attached plans. <br /> Plumber's Name(Print) Plumber's <br /> W � S�igGnaN_-re — �MP_/MFRS7Number Business Phone Number <br /> .AL <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -5-qf 7.Z --- <br /> VII ._County/DVartment Use Only_ i,�t attire <br /> 11 ------ <br /> -permit f w Date Issued � issuing,Agog <br /> Approved Disapproved g rJ t <br /> El Owner Given Reason for Denial 54j2010 - — - ----- -- <br /> IX.Conditions of Approval/Reasons for Disapproval 7 <br /> Attach to complete plain for the system end submit to the County only on paper not less than N Ila x 11 Inches I. fee <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />