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commerceml.gov Safety and Buildings Division County. '{7� <br /> 201 W.Washington Ave.,P.O.Box 7162 C <br /> iseonsin Madison,W153707-7162 Sanitary PermitNumber(lobe filled in by Co.) <br /> Department of Commerce 5511 <br /> Sanitary Permit Application Stale Transaction Number <br /> 1-/-In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (I 3g-o+ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms 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.1 S. 1 m,Stan. 23 ('74 OUI. Application Information-Please Print All Information <br /> 9W '36 <br /> Property Orwner's lame Parcel# 67- 006•+0? <br /> L 38-x]-jGS <br /> i� 4 /�o e-FS X35 7 Ors_ 00.2- <br /> Property Owne/r's Mailing Address Property Location <br /> 3 6 7 w 3 Govt.Lot C <br /> City,State, Zip Code Phone Number / <br /> C \ `� Section <br /> cam' hJ 7 .� Y�72 ucle one <br /> T�N; R, E o(D <br /> II.Type of Building(check all that apply) 2 lot# <br /> (or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> r— Block It <br /> O Public/Commercial-Describe Use <br /> ❑City of � <br /> ❑State Owned-Describe Use <br /> �' CSM Number O Village of <br /> V/ �� �11Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) — <br /> A' O New System Alacement System O Treannent1liolding Tank Replacement Only O Other Modification to Existing System(explain) <br /> ) <br /> B. O Permit Renewal O Permit Revision O Change of Plumber O Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> O Non-Pressurized In-Ground O Pressurized In-Ground OM-Grade Ic.r Mound>24 in.of suitable soil O Mound<24 in.of suitable soil <br /> O Holding Tank O Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> s I s'�e 1"-6-6 163,-5-- <br /> VI. <br /> 63-.sVI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existin Tmka W " V .o. <br /> s Bo 8C 83 8' B is <br /> a V in N <br /> Septic or Hdrd gg Rank vD <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> �de a/•�, 6J 2z��9 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 4C;K S/ -5 i/'e ,..) ZS )-Or <br /> VIII.County/Department Use Only <br /> Approved O Disapproved Permit Fee Date Issued Issuin g Signs <br /> 75 �zszar <br /> ❑Owner Given Reason for Denial tB rc <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 Inches in size <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />