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commereemi.gov Safety and Buildings Division County; <br /> 201 W.Washington Ave.,P.O.Box 7162 G( y!q <br /> tiscons i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce L I.� <br /> Sanitary Permit Application StwcT cion Number `r <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental f-/ LICM2 <br /> unit is required prior to obtaining a sanitary permit. Note: Application fors for statebwned POWTS are Project Address(if differeat than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> 2urposes in accordance with the Privacy Law,s.15.04(I)m,Slats. / <br /> I. Application Information-Please Print All Information 1 / Q t Wi 't4,k c <br /> Property Owner's Name / parcel# <br /> ' /f u.tvx f 6al-v l � S *V4VV, -oY� 38-f x-08-3 03 — <br /> Property Owner's Mailing Address Property Location 000-old-000 <br /> oleJ`r'� `-"�t't" Q_ Govt.Lot p� <br /> City,State Zip Code Phone Number c-t i/ yt S(V y,, Section O <br /> C/0 L 3,5'01- �/T y/63-Sa30 v`3 QC" (circle one} <br /> II.Type of Building(check all that apply) Lot# T¢N; R�_�_Eor <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSMNumber ❑village of <br /> Town of J6 0 /✓-e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) ID_ <br /> A. ❑New System D�da Replacement System y W Rep ys ❑Trcatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Number ❑Pmnit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 1/—O—OQ <br /> IV.Type of POWTS S stem/Com onent(Device: Check all that a I O( <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>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( d) Design Soil Application Ra[e(Wdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> fIOC`l e 'RS-1 p p3' 7,,.5_ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks w e V <br /> Ro <br /> a U in y ti ii.C7 M <br /> sepee l(oldingTank '70 pp 2. t<Jt User K <br /> Dosing Chamber <br /> VA.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb e sSignature MP/MPRS Number Business Phone Number <br /> e(S f O U/� U1,2'z 7/f G-Sr-d <br /> Plumber's Address(Street, ity,State,Zip Cod ) <br /> t(SCo 9j � <br /> yTII County/Dep.rtment Use Onl <br /> Pe <br /> Approved ❑Disapproved rmit Fee Dale Issued Issuing S attire <br /> /� I s <br /> ❑Owner Given Reason for Denial �!� 9 .�ji <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Aeach to complete plans(or the system and suhmit to[he C000ty only on paper not less than 8 M r 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />