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commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 f} <br /> is co n s i n Madison,W 153707-7162 Sanitary Permit umber(to be filled in by Co.) <br /> toopiartment cf Comrnunce 93 <br /> Sanitary Permit Application SheTransactionNumber <br /> In accordance with s.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 POWfS are Project Address(if different thsnmailingaddress) <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. i m,Stats. <br /> 1. Application Information-Please Print All Information 7- <br /> Property Owner's Name Parcel# <br /> 1 <br /> P1OF 's MLg Ae <br /> Property Locati n <br /> S//, .- e Govt Lot / <br /> City,State Zip Code Phone Number S' Y., Section 2 s7- <br /> s tCL' S-Of1 fjr- y�Z - ps (circle one) <br /> T�O _N; R�Eor® <br /> II.Type of BuBdin (check all that apply) Lot# <br /> 0 or 2 Family Dwelling-Number ofBedrnnms Subdivision No _. <br /> Block# of v l <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> fg?own of elexcKI <br /> J a- <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B it applica e) <br /> A. ❑ New System ❑Replacement System 2ITreatrnrnt/Holding Tank Replacement Only ❑ Other Modif cation to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Transfer m New <br /> List Previous P it Number and Date Issued <br /> Before Expiration Owner 3 9—/O--74 <br /> I V-T e of POWTS S stem/Com nentlDevice: Check all that apply) <br /> Non-Pressurized In-Gmund ❑ Pressurized N-Ground ❑At-Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound<2 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DLs ersal/rreatment Arm Information: <br /> Design Flow(gpd) Design Soil Application Rae(gpdsf) Dispersal Ates Required(s0 Dispersal Area Proposed(st) System Elevation <br /> N <br /> VI.Tank Info Capacity inTotal #of Manufacturer Gallons Gallons Unin e U <br /> New Tanks Existing Tanks m e u <br /> � U in 15 N izV a <br /> 2 O E f ✓ <br /> Dosing Charter 'v <br /> LL Rx' ✓ <br /> VII.Responsibility Su[emeat-1,the aadersigned,assn peasibilky,for lasularok of tke POWTS showy on the attached planes. <br /> Plumber's Name(Print) PI Signature ,� MP/MPRs Numher Business PhPhoneNumber <br /> FOg'6AT d Iv—114Y—701V <br /> Plumber's Address(Street.City,Sine,Zip Code) <br /> a 3 /lolL.rv� cRF�I/ <br /> Villll.Court /De artment Use Only <br /> 1.11�Approved 11 Disapproved Permit Fee Date Issued Lssuing A igtwture <br /> 11 'Owner Given Rayon for Denial s/C:.f/ f �/ <br /> IX.Conn�d�ition/s of App/rovaVRmsons for Disapproval / L <br /> T9 C/ <br /> --wt /vb F+rfllsl.+.. <br /> cc—(( 15 (.t�sl�evsTxt:4 ,sae- X1-4. I�" <br /> Attach to complete plants for the system and submit to the County only on paper not less tha II t incb e (4 Mul <br /> ISIS V ILI rU-r^ <br /> BUR ETT COUNTY <br /> SBD-6398(R.01/07)Valid lhru 01/09 ONING <br />