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co m erceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> isconsin Madison,WI 53707-7162 <br /> Sanitary Permit Number(m be filled m by Co.) <br /> Deparb„ern«Ca„n>brce4&,5&60 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to die appropriate 8 ova ancrual —U W <br /> unit it requiredd.toth prior rt obtaining a sanitary permit Nom: Application forma for yt be use ed POWTS are project Address(if di$'aent than mailing address) (� I <br /> submdied b the Department of Commerce. Personal nrformatiom you provide may be used for secondary `�TIV� y J <br /> purposes im accordance with the Priv Law,a.15. I m,Stats. L✓E'd f � �" /�� <br /> L A licatim Information-Please Print All Information <br /> Ui <br /> Property Owner's Name Par«18 0}Obj4•YlY) -,,&S 003 <br /> PA; 1 /Ce/a< t D. , tt61EiL D�3o <br /> Properly Owner's Mailing Address Property Locative <br /> T e o ;41ar k'e < Govt.Lot <br /> city,state Zip Code Phone Numbs Y., Yy section <br /> Gti�n hAtjjeh /Y/NeP94/ (eaebmro <br /> IL Type of Building(check all that apply) U Lot# T YO N, R /Y E <br /> ®1 m 2 Family Dwelling-Number ofBedmome / 3 Subdivision Name <br /> Block# <br /> ❑Public/Commacial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSMNumber7 ❑Village of <br /> I/41 Ra08 ®Town of .ieiYf' <br /> IIL Type of Permit: (Check only onebonsm Ime A. Complete tine B if applicable) <br /> A. 91 New System ❑Replacement ) <br /> ya Rep System ❑ Treatmeni/HaWing Tack Replacement Ody ❑Other Modificative m Existing System(explain) <br /> B. ❑permitRmewal ❑Permit Revision ❑ChsogeofPlumber ❑PennRTramferto New List Previous permit Number and fate Issued <br /> Befom Expiration Owner <br /> IV.Type of POWTS 4m/Com ent/Device: Check all that apply) <br /> 1@Nve-Preuurixed L-Ground ❑Presurirad 1n-Gruund ❑ At-Grade ❑Momd>2A im.of su0able soil ❑ Mond<yl in,of suitable soil <br /> ❑Holdhrg Tent ❑Other Diapersal Component(expla al ❑pmtmadmau favi«(cxplam) <br /> V.DispmalfFreahateat Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dir al <br /> O� pas Area proposed(at) System Elevati o <br /> . 7 8s 7 ills q 9y a 93./ <br /> VL Tank Info Gpalloy in Tohl #of 'c'— yy <br /> Gallon GaRom Unita y o'yy$$ o <br /> New Tanks fixating Tmila 9la 3 <br /> Septi.or Holding Tank IA&0 <br /> rxang ch.nx 7 S o Ire <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Phrmber's Name(Print) Plrrrmber'e Signature J/ W/MPRS Number Busurce,phone Number <br /> /foie—A f�o �r-rf / /7 �lrBS� 715— n6-4rr7 <br /> Plumber's Addr—(Skeet,City,State,Zip Code) <br /> 774'0 3S- t�t/L'�isf e� urs'S4 893 <br /> VIIL Cam /De arts amt Use Only <br /> Approved ❑Disapproved PermitF«,l Date Issued Lwin Signa <br /> ❑Owner Given Resaon for DenLl S 250 () g7J✓Ly <br /> D (bndiii—s of Approval/Ressona for Disapproval <br /> Almeh m eomphte phis for We system and sbma m the County only on Paper"les theal;in all imbes h she <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />