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Amb commeroeml.gov Safety and Buildings Division County _ <br /> a 201 W.Washington Ave.,P.O.Box 7162 �u r/I e <br /> i sero n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department Of Commerce )3 a <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �f\/ <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different 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 Privy Law,a.15. 1 m),Stats. Gd JS <br /> L Application, m <br /> licatiInforation-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ,6i l l Cu Sh ane n C� Oa ff- y/OH - off/o0 <br /> Property Own«'s Mailing Addreas Property Location <br /> J <br /> ld lvr 05 e tilde Govt Lot _I— <br /> city, <br /> City,State Zip Code Phone Number <br /> Yy Y., Section <br /> /I�oSCv;(le /y1N 6si/3 T�N; R �4�Eo�t52 <br /> sIIL� Type of Building(clieck all that apply) Lot# <br /> d11 <br /> .C!1 or 2 Family Dwelling-Number of Bedrooms; 1- Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number ,` ❑village of <br /> U-T A-� ..� Town of .SCe <br /> III Type of Permit: (Check only one box en Kne A. Complete tine B if applicable) <br /> A. ❑New system '- . <br /> ye EO — <br /> lacement System 0 Trestment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewalit Revision eoIPlumber List Previous Permit Number and Date issued <br /> ❑ Chang Permit Twofer o New <br /> Before Expiration Owner <br /> �xIyV.T of POWTS Sy heat/Component/Device: th <br /> ent/Device: Check all at apply) <br /> vy Non-Pressurized In-Ground 0 Pressurized In-Crround 0 At-Grade 0 Mound>24 in of suitable sod 0 Mound<24 im.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V. aVfreabment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdaf) Dispersal Area Required(at) Dispersal Ann Proposed <br /> 3o O s Pere (� System Elevation <br /> baa 6ao 4.s o <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> Gainers Gallon Units U g <br /> New Tank, Existing Tanks <br /> Septic m Holding Tank <br /> Dosing Chamber <br /> VIL Respmssibltity Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signture IN/MPRS Number Business Phone Number <br /> t�l�h o <br /> Z?5851 715. 86L- 4/57 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27760 5&a e- /L s ",, w 5 8 93 <br /> VII Came /De tUrse0rdy 141 <br /> e Ont <br /> Approved 1 0 Disapproved I Permit Fee Date Issued Iseamg Ag Wait- <br /> 13 <br /> lure <br /> q4t T <br /> ❑Owner Given Reason for Denial Z � (/Juste <br /> IX Conditions of ApprovaVReasons for Disapproval <br /> Attach to wa.pkle phss for she sysha moil submit to the Comay only as pepor rot ks Wena 8 in x It Wbft in.&. <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />