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commerceml.gov Safety and Buildings Division county <br /> 201 W.Washington Ave.,P.O.Box 7162 ;jy r rl/<✓ <br /> i s eo n s i n Madison,W1 53707-7162 Sanitary P it Number(to be filled in by Co.) <br /> Departmem of Commerce ryumZy0 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Contra 83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application fors for state-owned POWTS <br /> submitted to the Deparmml of Commerce. are Project Address(if different than mailing address) w <br /> Personal information you provide may be used for secondary ^n <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. 15-616e4pp W <br /> 1. A m <br /> Application Information-Please Print All Information . 55-335-616e a,; <br /> Pro' /pe/rty,Owner's Name Parcel q <br /> Property Owner's Mailing AddressO O C) <br /> Property Location <br /> SS3 <br /> State Govt Lot <br /> Gly, <br /> / Zip Code Phone Number /'l/C-Ys, Section .2 y <br /> y ' C cycle one <br /> IL Type of Building(check all that apply) Lot u T�L N; R/b _E <br /> 54or 2 Family Dwelling-Number of Bedrooms r-"-- Subdivision Name <br /> Block H <br /> ❑Publie/Commeroial-Describe Use <br /> - - — -'— ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of_ <br /> Town of A,' G 4rr✓O a'%-J__ <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> A. ❑ New System rrrrrryyyyyy______ <br /> y eplacemen[System ❑ Treatment/Holding Tank RepLcement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Perit Renewal ❑Peril Revision ❑ Change of Plumber ❑Peril Transfer to New Liat Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade RMouml>24 in.of suitable soil ❑ Mound<24 in.of 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 /> and / 3 o C) 3oa <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallo. Units <br /> New Tanks Ezisling Tanks w e O C 8 y <br /> Septic or HONeg-T'ook, <br /> S� <br /> Dosing Chamher 1114 <br /> �O C) OQ / <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 Signature MPIMS Number Business Phone Number <br /> l9 /AA 1 z769/ 3e/,9-7��6 <br /> Plumber's Address(Street,City,State,Zip Code <br /> ,doe s/5' s . "- g --) s y <br /> VIII.County/Department Use Ont <br /> Approved ❑Disapproved Permit FFeeee Date Issued Issuing gmum <br /> $ <br /> ❑Owner Given Reason for Denial <br /> IX Conditions of Approval/Remons for Disapproval frc1L <br /> Ah IImd E1154le veoFa a,3 APruc 'o t3 <br /> Mach to complete plans for the system and submit to the County only an paper not lea than a In x it inchm in alae <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />