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I <br /> C4iri171@i'C@.Wi.gOV Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 6"V ?tt <br /> isco n s i n Madison,WI 53707-7162 Sanitary Permi Number(to be filled in by Co.) <br /> Sanitary Permit Application S��Transao n`Number <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 POWTS are Project Ad (if different 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. 1 m,Stats. ply SO /"es <br /> 1. Application Information—Please Print AD Information v <br /> Property Owner's Name Parcel# <br /> /?a ZOOS 7" (�` 036 - 901T'S -o y 6oa <br /> Property Owners Mailing Address Prey Lava on e a Q j jJ <br /> �r Ot A - )&w e.S /t /e Govt.Lot <br /> City,State Zip Code Phone Number yy y., Section 3 6 <br /> rti MAl 5'Y'ia <br /> St Fa ! s 6x-1- 6 SO- 3 879 (eacleone <br /> T �/O R /7 E oqy <br /> IL Type of Building(check all that apply) Lot <br /> ®1 or 2 Family Dwelling—Number of Bedrooms � Subdivision N e <br /> Block# 1• <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned Describe Use CSM Number ❑Village of -- <br /> — Town of I >T/d H <br /> IlL Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> A. ❑New System B Replacement System ❑TrestmenvHolding Tank Replacement Only ❑Other Mod'rcation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous F ermit Number and Date Issued <br /> Before Expiration Owner <br /> rV.Type of POWTS System/Component/Device: Check all that a I <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground Q At-Grade ❑ Mound>_24 in of suitable soil ❑Mound<2 4 is of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(captain) _---___ _ ❑Pretreatment Device(explain) <br /> V.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required(of) Dispersal Area Proposed(sf) System Elevation <br /> 300 7 4/�5 `/.7.4 1 9v o <br /> VI.Tank Info Capacity in Total k of Manufacturer <br /> Gallons Gallons Units U <br /> New Tanta Existing Tonks X Q <br /> S-pnc or Holding Tank Si0 s..+ X <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the aft wbed plans. <br /> Plumber's Name(Print) Plumber's Signature MP1MPItS Numb Business Phone Number <br /> /C/G /7 le 4 kI n J �� d`�✓rB.SI 71s-8�i 6� y/S-7 <br /> Plumber's Address(Streeet,,City,State,Zip Code) <br /> 77 /7 w �� (��6s7C/ I- <br /> VIIL Camtv/De artment Use Only <br /> Q�Approvcd ❑ Disapproved Permit FeeDate issued '"] Isenrtng Signature <br /> ❑Owner Given Reason for Denial S �(J� *Q ! / <br /> IX Conditions of Approval/Reasons for Disapproval <br /> Attach to compkte pima for the system and submit to the County only an paper not km thm%8 is x It inchn in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />