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commereeml.gov Safety and Buildings Division Cow <br /> 201 W.Washington Ave.,P.O.Box 7162 uv'n f°� <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) ( �i <br /> Departmenmme <br /> t of Corce 532 117 le �!� <br /> Sanitary Permit Application State Transaction Numb" fv1V1 <br /> In accordanceComm. <br /> with a.Com83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 110932 32!f <br /> unit is required prior to obtaining a sanitary permit Now: Application forms for state-owned POWTS are Project Address(if different thanmailmg address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary �J <br /> purposes in accordance with the Privacy Law,s.15. 1 m),Slats. <br /> I. Application information—Plea a Print All Information dh .f. ✓plr risen <br /> Property Owner's Name Parcel# <br /> tine d- Lafora Wei,rfetr—k I� 0aa — y3o� 3— o"300 <br /> Property Owner's Mailing Address Property Location <br /> a1 / d03 ReLso FIAO Cfrcltn Al Govt.Lot 6 <br /> City,State Zip Code Prone Number <br /> Y., Y., Section <br /> e r Cd 1f- L/G pt N (circle one <br /> IL Type of Building(check a6 tlmt apply) Lot# T 40 N; R /(v E o f V) <br /> ®l or 2 Family Dwelling—Number ofBedmorm at Subdivision Name <br /> Block# <br /> ❑PubfidCommercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> ®Town of <br /> III.Type of Permit: (Check only one box online A. Complete line B if■ppUmble)p _ <br /> A. ❑New System Replacement System TretmontlHohf 8Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑PermitRenewal ❑Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS tem/Com onemb Device: Check a6 that apply) <br /> ❑ Non-Pressurized ImGmund ❑Pressurized Lr-Ground ❑ At-Grade ❑Mowd>_21 in.of suitable soil R Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑otherDispcnal Component(explain) ❑Pretreawmt Dcvice(explain) <br /> V.Dispersalfrreatruent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 300 300 99, i7 <br /> VL Tank Wo Capacity in Total #of Mamrfacmrer <br /> GaBom Gatom Units <br /> New Tmks heisting Tarlo S o B ab <br /> Septic or Holding Tank 7r0 7S0 <br /> Doing Chamber sea Stso <br /> VIL RespoftsibBity Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Burmese Phone Number <br /> A?le- o klm s / •� at�,f&S-i acf P66-psis 7 <br /> Plumber's Address(S City,State,Zip Code) <br /> d 7760 Hon 3S Lf/e6.t;Kwr W77 Sr/843 <br /> VIIk Cozen /De artment Use Only <br /> Approved 1 ❑Disapproved PermitFee <br /> ',r� Date Issued Iseuimg rgmlure <br /> ❑ Owner Given Reason for Denial S 375- <br /> DL <br /> /5i 1�� 65 <br /> DL Conditions of Approval/Reasoo far Disapproval <br /> Atbeh to eompkte plan for the system and submit as the County only an paper not less than 8 n2 a 11 Inches In she, <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />