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carnrtlerce.wi.gov Safety d Buildings Division County49611b �,1[ <br /> 201 W.Was 'ngton Ave,P.O.Box 7162 'A r n e l t <br /> 'Wisconsin MadlommIt, M 53707-7162 Sanitary'/Pet t Number(to be filled in by Co.) <br /> epartme t of Cerce ry-q '4-55 <br /> Sanitary Permit Application State Tonsae on Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this forin to the appropriate govomtaual /38 �-5 <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for stateowned POWTS are Project Addy (ifdifferent than mailing addresa) <br /> submitted to the Department of Commerce. Personal information you novide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1 m),State. �• <br /> L A lintimfo <br /> Inrmation-Please Print AB information .� �S� 9Gf4MAor �Lf <br /> Property Owner's Name Parze-WO-0/6000 <br /> Jo•, Lve!/QN 3a0 d o ys�a oasoa <br /> Property Owner'a Mailing Address <br /> "� Prrger�ty Las'on <br /> �d�� /f al fch/nJ CT &S -AX0 <br /> City,State Zip CodePhone Number N w Yy w Yy Section 10 <br /> G�IaS/�a /HAv Srs/a 9d',t- lw- 38sd (Circle one) <br /> 3 <br /> IILType of Building(cheek all that apply) Lot# 2 T 4"O N R 1k E mdP <br /> plt lor2 Family Dwrdltg-Number of Bedroom Subdivision me <br /> Block# <br /> ❑Public/Conn acial-Describe Use <br /> ❑Cityof <br /> ❑State Owned-Describe Use CSM Number f3B490 ❑Village of <br /> V'I1MGSa4 A (( 1a Townof 0"f/e/4nae <br /> IIL Type of Permit: (Check only one box m line A. Complete • e B if applicable) <br /> A' ❑New S stem <br /> Y �Replacement System ❑Trzatmenutic kling Tank Replaccmcnt Only ❑Other Mod cation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ eofP ba List Previom it Numbs and and Date Issued <br /> Before Expiration Chang Own�ma Tramfa W New <br /> IV.Type of POWTS stem/Com ment/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized lo-Ground ❑ At-Grade ❑Mound>24 in of suitable soil [1Njkqrud<z is of suitable soil <br /> frHolding Talc ❑OtherDisperul Component(explain) ❑P.1reatment Device <br /> (explain) <br /> V. ersalfFratment Ates lnformatim: <br /> Design Flow(gpd) Deign Soil Application Rate(gpdaf) DispeTmUnits <br /> Dispersal Ares Proposed(at) System Elevation <br /> YsD — _ <br /> VL Tank hnfo Capacity t inner <br /> Gatlom }s�p� ' yy o <br /> New Tanks E,tistmg TwJrs . <br /> Septic alloldvg imaJc ,3®so <br /> Dbnrg Ch ber <br /> VIL Responsibility Statement-1,the undersigned,assume raponsibtl ty for installation of the POWTS shown on the att ed plana <br /> Ptmber's Name(Prat) Phunber's Signature MPMU RS Numbs <br /> Business Phone Number <br /> �JSBSJ 7rs=�6b vis-7 <br /> Member's Address(Sheet,City,State,Zip Code) <br /> 774;e hlwy 3.5— 4Je465Ie✓ k r S'7!89 3 <br /> V�IIL m Ca /De artment Use Ont <br /> rr <br /> p'A'pproved ❑Disapproved Permit Fee Dat Issued Issuing tore <br /> $ �t, <br /> ❑OwnerGives Reaeoa for Denial c� �'� -O/y <br /> IX.Cmditiotm of Apprw <br /> )ac . eF Arta Ar a» On•5/f SesC <br /> em--064 1.46P Rzi&-64J <br /> Attach m anoplee prem.for nh rystea omd..beer the Caaay anty m paper nice ho than a res III hichesir Was <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />