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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> co ns i n Madison,WI 5 3 70 7-7 1 62 Sanitary Permit rNe <br /> tL sNumber(o be filled in by Co.) <br /> partment of Cornmeal <br /> Sanitary Permit Application Sale '-a saction Numfb/rf l f ', <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (i(wN/� Kole..) <br /> ole..) <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 /> pw2oscs in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> 1. Application Information-Please Print All Information (� 4,2/ G V <br /> Property Owner's Name Parcel# <br /> --r—b In L 4,iU 0 3 '/M3 o a <br /> rropery,Owner's Mailing Address I, Property Location <br /> 3 A u e / Govt.Lot 3 <br /> Chi Sy,State,.Jl �r 1 Zip Code ry Phone Number _y,, y., Section V?3 <br /> circle one <br /> It.T e of Building ell all that apply) Lot# T_yo N; R E orWj <br /> YP B( PP Y) <br /> �(*or 2 Family Dwelling-Number of BedroomsSubdivision Name <br /> _ Block# <br /> ElPublic/Commercial-Describe Use _ <br /> ❑ City of <br /> 11 State Owned-Describe Use CSMNuumber ❑ Village of <br /> Vz/ P/66 ATown of. u/D,';mj <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ _ _ _ D <br /> A. _ <br /> ODD <br /> ..KNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> yIV.'T a of POWTS S stem/Com onent'Device: Check all that apply) <br /> V.n <br /> y un-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.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(so System Elevation <br /> —300 7 9 V15--o <br /> Vt.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °= <br /> o v <br /> New Tanks Existing Tanks U <br /> a` U' yr <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Na a(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumbers Address(Street,City,State,Zip Code) !� l <br /> Vlll.Coun /De artment Use Ord <br /> Approved ❑ Disapproved Permit Fee Da/te$ I's/sued p Issuing A ature <br /> ElOwner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less Thane V3 x I I incM1es in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />