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cornmerceml.gov Safety and Buildings Division County '7 <br /> 201 W.Wasltington Ave.,B0.Box 7162 U(Al <br /> t1upsarbasuntseonsin Madison,WI $3707-7162 Ssnitary Permit Number(W be filled in by Co.) <br /> of Commerce 52 / pb <br /> Sanitary Permit Application State Tmm,.cfion Number a ' <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to thea appropriate governmental <br /> unit is required prior to obtaining a aani App tato-o 8 w <br /> submitted to the ceY permit Note: Application forma fmybeo,ed POWTS are project Address(ifdifferen[tban mailing address) <br /> Department the <br /> of Commerce. Personal information you provide may be used for secondary <br /> sere in accordance with the Priv Law,s.15.04(i)(m,Stets. <br /> L Application Information-Please Print An Information G r e,e Yt 7-r'.I i O <br /> Property Owner's Name I L parcel# <br /> a" ff An f ,moi- 3350 6 M - vzab , of yon <br /> Property Owner's Mailing Addreres Property Lmc-fi- ems.of w 11W of <br /> /98/ 0& t,1.1, sr <br /> City,State Zi Code Govt Lot S <br /> P Phone Number 6 <br /> /r•A �a weB rnN. Yh Yti Section <br /> IL T SS IQ 9 �i.S-/- yay. 9�/71� T �� N; R /.'e(circle ono) <br /> Type of Building(check sU that aPP1Y) Lot# <br /> ® l or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> ola-a-qC`/. <br /> Hlock# o"j IS <br /> �_ <br /> ❑PubadCommereiCCG—OZ7000 <br /> al-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSMNumber 0Village of <br /> !J Town of OA4 Ks o n <br /> Ill.Type of Permit (Check only one boa on line A. Complete line B if applicable) <br /> A, 0 New System <br /> Replacement System ❑Treafinent/Holding Tack Replacement only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber 0 permit Transfer to New LIPrevious Permit Numberand Date issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> RNmr-Presamlzed In-Ground 0 pressurized In-Groud 0 At-Grade 0 Mound>24 in.mf suitablesoil 0 Mound<24 in.ofsuinble soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Preaeatment Device(explain) <br /> V. ersaVl'reabnat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdet) Dispersal Area Required(at) Dispersal Ares Proposed(at) System Elevation <br /> SS'o s- 900 900 9SqV <br /> qVL Tank Wo Capacity in ToW #of ManufacturerGaaom Ganmm UnitaoNew Tank. Edsting Tanks , bpfTSA- W t� ipd <br /> Septic mBoWing Talc �e OG /000 <br /> Dosing Chamber Bl7 <br /> 00 <br /> VII.Raponsibinty Statemat-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPR 1 Number Business Ph N.Number <br /> h/v k,N s /. <br /> Plumber's Address(Street,City,State,zip Code) oU J <br /> , ' 7760 /�w 3_� Gt>�3frs � rJ_� Slld4� <br /> VIIL C2Mu_tyTejpartmcnt Use Ord <br /> Approved 0 Disapproved IPermit Fee Date Issued Issuing Agent . <br /> IIII <br /> ❑Owner Given Reason for Denial 325 �0/V78V(iL O /p <br /> v <br /> IX.Conditions of ApprovsUReasons for Disapproval <br /> Attach to complete plans for use system and whisk tothe Counly only m paper tut Ise thae a irs:11 teeter b aim <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />