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eommerce.wl.gov Safety and Buildings Division County �/� <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be <br /> 201 W.Washington Ave.,P.O.Box 7162 (A r n f4' <br /> filled in by Co.) <br /> apartment of Commerce 551 L 5 <br /> Sanitary Permit Application State Transaction Number <br /> Curran. \ <br /> In accordance with s.Co .53.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 1 9 J 9 1(p o <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stale-awned POINTS are Project Address(ifdiffi r t 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,e.15.04(1)(m),Stats. O d,I /IIs �r e <br /> I. A m <br /> Application Inforation-Please Print All Information O <br /> Property Owner's Name Parcel N <br /> -5,A MY Jeltn-evil *T�5 o5- C'(54-& IA eve <br /> Property Owner's Mailing Address Property Location <br /> ey( N I YO✓IL Al/G S• Govt.Lot _ <br /> City,State Zip Code Phone Number <br /> Y., Ys, Section 2 � <br /> �S /hNSS'f•//t' (circle one) <br /> SZO N; R 144 E <br /> � <br /> pILr Type of Building(check all that apply) Lot# <br /> T <br /> Al 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Numberm❑ Village of <br /> V-2 () /d e OI Town of .Se a <br /> ILL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ENm em � R lacement S stem ❑ Trestment/Holdin Tank W ap y g Replacement Only ❑Other ModiEoation to Existing System(explain) <br /> B. newal ❑ PennilReviion ❑ Change ofPlumber ❑Permit Transfer to New ListPreiousPermit Number and Date issued <br /> ation Owner <br /> IV.Type of POINTS S stem/Com onent/Device: Check all that apply) <br /> ❑Nov-Pressurized In-Ground ❑Pressurized In-Ground ❑ Al-Grade g Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable..it <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Tmatinent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> a C I /.ot I 3oo 339 9G• S <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 ° o <br /> New Teal. Tanks u $ A <br /> 0 p <br /> di U v7 9 �n i4 C7 W <br /> Septic or Holding Tank '7S0 7d'D <br /> Dosing Clamber <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /7o�dkrns / 4-,� ddSSs / 7/f86G-4�s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 /1 - 3S w-0,dsfr w1 Sef��i3 <br /> Vill.Court /De artment Use Only <br /> Approved ❑Disapproved Per id Fee�/p}} W DateIssuedIssuing Sigmture <br /> ❑Owner Given Reason for Denial S�J7 ,1Z ,V <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to eomplete plow for the system and=limit to the County only on paper not his than 5 in:11 titch"In size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br /> x <br /> 1<. <br /> a• <br />