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corrpmerCC.Nrl.gov Safety and Buildings Division County /� <br /> 201 W.Washington Ave.,P.O.Box 7162 /J k/ ) P <br /> tM n s!n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> s�f-o 3z <br /> Sanitary Permit Application state Tran <br /> N//umber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental C�p/r✓'G sJ /t�,(Z(Gfst/ <br /> unit is required prior to obtaining a sanitary permW, Note: Application forms for state-owned POWTS are Projea 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 PrivacyLaw,s.15.04(l m Stats. ^�^_ �✓ <br /> I. Application Information-Please Print All Information Tea;1!66x <br /> Property Owner's Name >pcS� /t'.Z. t(�-I�l.�r-!J' / -0'j0' <br /> ���3 Lja U� �/z yo/S�as�so�-e�9ed <br /> Property Owner's Mailing Address Property Location <br /> /� Q '/- H Zn 4,11 T,../Gist Govt.Lot <br /> City,State ''..// T Zip Code Phone Number „f,E" '/. ME '/., Section e2 <br /> 14)2 6 5l e,- Wl ��11�� .(_circle one) <br /> II.Type of Building(check all that apply) Lot# T `FI/ N; R E or� <br /> I or 2 Family Dwelling-Norther of Bedrooms 79 t/r 79 Subdivision Name <br /> Block# 4e,7 ?D Ud YU P/' <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSM Number El Village of <br /> YTownof <br /> III.Type of Permit: (Check only one boa on line A. Complete Bot B if applicable) - -� <br /> `t, ❑New System P Replacement System ❑Treatment/Bolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POINTS System/Component/Device: Check all that apply) <br /> KNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade D Mound>24 in.of suitable soil ❑ Mound<24 inof 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(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> ��O S 900 900 `jS, <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units d V$ <br /> New Tanks Existing Tanks "�- c .o. <br /> rt V in ti oo ii C7 M <br /> Septic or Holding Tank I //a f/-Gli <br /> Dosing Chamber b a4f0 m <br /> VII.Responsibility Statement-1,the uadersigued,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plum Signature MPIMPRS Number Business Phone Number <br /> Plum,�'s Address(Street,City,State,Zip Code) <br /> llo 4 a411 <br /> VIII.Couoy?�!!partpaaent Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing A lgnature <br /> $ 7 <br /> 11 Owner Given Reason for Denial 3,? 09 SV( ,tp10 <br /> r7onditi ons of Approval/Reasoas for Disapproval <br /> Attach d rompkle pleas for the system mad submit an the County only on paper not has dram A 1I2 x 11 lathe I.sire <br /> SBD-6398(R.07109)Valid tlnu 02111 <br />