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cmfC""gov Safety and Buildings Division County pp <br /> a 201 W.Washington Ave.,P.O.Box 7162 06a✓h e <br /> t1:0SP,09-,9-te-nt s n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ommons 4-66(,03(- <br /> Sanitary <br /> -B6 3Sanitary Permit Application State Transaction Number I „ <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if diffoent 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 Privacy Law,s.15.04(1)(m),Stats. <br /> L Applicatim Information-Please (osm <br /> Print AB Inati ,$6z5YRe's kAV <br /> Property Owner's Name Parcel9 <br /> LEiv.se oz8 4110 04300 <br /> Property Owner's Mailing Address Property Location <br /> �4.,, N. Govt.Lot_l__ <br /> City,State Zip Code Phone Number <br /> Yh Yh Section /o <br /> ?( M70.f (� /17/� SS4 Y G n-T-xa-,, - / G Sy T N; R // CiMEoorre)— <br /> IL Type of Building(check all tlmt apply) Lot N <br /> 1 or 2 Family Dwelling-Number of Bedrooms Parce Subdivision Name <br /> Block R <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of /" <br /> Va P. 11 ® Town of_ .7c prr�� <br /> Ill.Type of Permit: (Check only one box m line A. Complete tine B if alippcable) <br /> A. ❑ New SystemOrRplimmucad System ❑Treatment/Holdiall Tank Replacement Y O Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transferm New <br /> List Previmn Permit Number and Date Issued <br /> Before Expiration Owner <br /> TV.T of POWTS S stem/Com onent/Device: Check al that apply) <br /> allon-Pressurized ln-Ground ❑Pressurized In-Gmuud ❑At-Grade ❑Mom l>2A is of suitablesoil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tads ❑Other Disposal Component(explain) ❑Pcehameat Device(explain) <br /> V.Digpersalfrmatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(of) Dispersal Area Proposed(at) System Elevation <br /> 17 1 7 1 6u3 6 ysr 9s o 1-7,v- <br /> V1. <br /> 9yVI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Unita a ' U 'F <br /> New Tanks Maung Tanks <3 id <br /> Septic or Holding Tank �t90O 1000 <br /> Doing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's <br /> Plumber's Signature MPMIPRS Number Business Phone Number <br /> /2hc /'� <br /> &G 110,41e, c�wQ /� elfs�Sl 94a- clIX7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> )77G0 Tf webs�r � /vim — �—`t843 <br /> VIIL Coup /De artmont Use Only <br /> Approved ❑Disapproved <br /> Permit <br /> .Fee <br /> DateIssuedIssuing Agena <br /> ❑Owner Given Reason forIkoial S /�✓[/ �WU �� <br /> D{.Conditions of Approval/Reasons for Disapproval <br /> Math to complete pans for the system and submit to the County only on paper not len than 8 rte 111 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />