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eommeroe wLgov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Ili w2ite� <br /> Sc o n n Madiw.ni of commaeow WI:33707-7162 <br /> $a D. 1. Number(to be filled in by Co.) <br /> 'Mclas3z lsrp � <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm 83.21(21 Wis.Adm Code,submission of This form to the appropriate govemmaoW 601 QC()ILct) W <br /> unit is roquiredprior m obtaining a sanitary pomalL Note: Applidauon forms for state•owned POWIS sre Project Address(ifdifferent then mailing address) <br /> submm the e Department of Commerce. Personal information you provide may be used for-sewndaty <br /> purposesaccordance with in accordanwith the PrivacyLaw,s.1 S. 1 m Stats. <br /> I. Application11110mation-Please Print All Information Z9Z 3fJ 'Dxt.(4R-`D2 <br /> Property Owner's Name Poral# ( tiT <br /> 1300 oz�-clt4o-oz LzOD <br /> Property Owner's Mailing Address <br /> Property Location <br /> 47 f YAR lE Lwf, Govt.Lot <br /> City,Stam '1 Zip Code - Phone Number <br /> JA le CanNdn _rrin S6 '/� 3e Y" Section 3 <br /> 55111 ('51-y87rg1 zy' (circle on <br /> It.Type of Building(check ALI that apply) Lot# T10N; R1_Eo W <br /> m l or 2 Family Dwelling—Number of Bedrooms Z-- I� Subdivision Name <br /> # _f�tt✓i 6q'1'_.. �.. <br /> ❑Public/Commercial-Describe Use Block <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Numbs ❑Village of <br /> Town of c�56 tt' <br /> III.Type of Permit (Check only one box on Ise-A. Complete Una B if applicable) _ a <br /> A �of - ' - !-urnber <br /> S- 5 565=-0 <br /> ptNew System. ❑Replacement Systems ❑Treatsnull/holding Tank Replacenent Only ❑Other Moto Existing System(explain) <br /> B. ❑ Permit Renewal ❑PumR Revision ❑Change of Plumber ❑Permit Tramfer to New List Previous and Dam Issued <br /> Befoie.Expintion Owner �5a20Z 20e; <br /> 4;2 <br /> IV.Type of PO <br /> WI'S Sys onent/Device: Check all that APO <br /> �I Non-PteasuAz d In-Ground ❑Pressurized ho-Ground ❑At-Grade ❑Mound 24 in.ofsuitable son ❑Mound<24 in of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Componem(explain) ❑Pretreatment Device(=plain) <br /> V.vis e,rsal/1'reatment Area Information: <br /> De sign Flow(gpd) Iksign SoU Appliatioq Rate(gpdot) Dispersal Area s <br /> Required(1) Dispersal Ara Proposed(sf) System Elevation <br /> 300 . S. 400 w00 '9�8 95.E <br /> 1'I.Tank Info Capacity in TO #of Manufacturer' <br /> Gallons ' Gallons Units <br /> New Tanks Existing Tanks a �� n u <br /> 6 V A � t%I 4 C7 G. <br /> Septic or <br /> 00 OO 6L44a1 <br /> Doling Chamber <br /> VII.Res ogsibili Statement-11 the Roden] Red,assume res omlbllity for Installation ofthe POWTS shown on the attached plans. <br /> P1 1YICR 57Cr'Il�i & EXCAVATION Plum a t MPhj&S Numbs Business Phone Number <br /> Plum r ys]9 <br /> IS4 Lay e <br /> .�9 <br /> VIII.Coun a artment se nl .. ._ <br /> Approved ❑Disapproved - Permit Fee. Date Issued Issuln a <br /> S <br /> ❑Ownsr Given Reason for Denial , S 7- 09 <br /> IX.Conditions ofApprove l/Reasons for Disapproval <br /> S016 Mapped d1 385 D- Afah6msidi , AMY , <br /> n1orE: rN]s kyr rs + RE rs a,« 6A SPS 3o&,�>Z s <br /> Attach b wmplab platy for the sysbm anti submit b this County only on paper nal Iw Ihw a N e 11 Inches In shs <br /> 4. <br /> SBD-6398(R 01/07)Valid slim 01109 <br />