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tcommerceml.gov Safety and Buildings Division County <br /> a a 201 W.Washington Ave.,P.O.Box 7162 ��f t r n e <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> artmem of Commerce 53 Z 13 6 <br /> Sanitary Permit Application State Transaction Number , , 1 <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental L KLV t�t� W <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms fm state-owned POWTS are Project Address(if differmt than mailing address) <br /> submitted to the Department of Commerce. .Personal information you provide may be used for secondary <br /> purpma in accordance with the Priv Law,a.15. l m),Slats. I <br /> L A Bcation Information-Please Print All Inforeati `✓Yah 6 t=-e-Y Meysh Allot <br /> Property Owner's Name Parcel# �1 <br /> sQ roc .40 C Cir-rn C'd :#�� 0 44-.A cF-O,-3 6 <br /> Property Owner's Nbiling Address p Property Locative <br /> R', Bok ze)o Govt Lot 5114 p <br /> City,State zip Code Phone Number S.0 Yy 5C— Y.((, Section <br /> .51 r e" kl r .�Y� 7�i 38 lSc�E one) <br /> IL Type of Building(check all dust Ni R o <br /> t apply) Lot# V <br /> �1 or 2 Family Dwelling-Number of Bedroom Subdivision Name <br /> Block# <br /> ❑Pubhe/Commermal-Describe Use ❑City of <br /> ❑State Owned-Describe UseCSM Number ❑Village of <br /> Town of <br /> Ill.Type of Permit: (Check only one box can fine A. Complete line B if applicable) _ _ <br /> A. qNew System ❑ lacem mt system ❑ TmAmicat/Holdin Tank <br /> vq! Y Rep Y 8 Replacwent�Y Q Othm Modification'to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Tramfer to New Lur Previow Perm it Numberand Date Issued <br /> Before Expiration Owner <br /> IV.T of POWTS S atem/Cmn ent/Device: Check all that apply) <br /> Z Non-Pressurized In-Ground ❑pressurized In-Ground ❑ At-Dade ❑Mound>24 in,of suitable soil ❑ Mond 124 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreahncat Device(explain) <br /> V. ' ersWrreamtent ArealnformatiM: <br /> Design Flow(gpd) Design Soil Application Rale(gpdat) Dispersal Area Required(at) Dispersal Area Proposed(af) System Elevation <br /> ';/So S F00 9,10 <br /> VL Tank Info Capacity in Total #of Manufacturer o e <br /> Gallons GaEOm Unit J <br /> New Tanks Examg Tanks <br /> Septic or Holding Tank /Do0 JCOn / .S/Gn .✓ <br /> Dosing Chamber x <br /> VII Respondbility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Prmt) Plumber's Signature, MP/MPRS Number Business Phone Number <br /> R/Csr " s �Ar eO lise o a <br /> Plumber'sAtate, vises <br /> Zip Code) <br /> A'77 6 O L-t eI64/-r✓ W r Srl�93 <br /> VIIL Cam /De •rtnent Use Only <br /> Approved ❑Disapproved Permit Fee =IssucdIssuing A S' toreOwner Given Reason fm DenialS9 ` <br /> IX.Condidms of Approval/Reaaotns for Disapproval <br /> Attachto coetsleh plow for the syahm and subdt tots,County only on paper not has the 814:11 inches In sin <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />