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commerce.wi.gov Safety and Buildings Division County y�— <br /> 201 W.Washington Ave,P.O.Box 7162 k N % G[r <br /> tiscons i n Madison.WI 53707-7162 Sanitary Permit Numbs (o be filled in by Co.) <br /> Department of Commerce 1 �I rI 2 W <br /> Sanitary Permit Application state 1 c6 Nu bee <br /> / =1 <br /> In accordance with s.Comm,8321(2),Wis.Adm.Cade,submission of this form to the appropriate governmental Wy.�G� 1�4(� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if ditTerem than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary U 1 <br /> Purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. Irl�/ Loh <br /> 1. A Bcatim Information-Please Print Ail Information 'I/L iZdr <br /> Property Owner's Name Farce]H <br /> ,Fd colaI',.s Cry-#3,105 oar v/oy a �8a3 <br /> Property Owner's Mailing Address ecomf Aotd/ess Property Location <br /> /O 5GO /boat, i4.e /!/• /vi 4Eh i5r NW <br /> City,State Zip Code 05SEO MAf ne _b3(o9 Govt.Lot <br /> %. _((i)h, Section <br /> 100 It 9 <br /> (cycle one) <br /> IL Type of Building(check all that apply) Lot# T 4G N; R_/Jl E ocv <br /> IK 1 or 2 Family Dwelling-Number of Bedrooms 0� 3 Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> El State Owned-Describe Use CSM Number ❑Village of <br /> vul /(, <br /> / 7 [Town of -10 a 10- <br /> 111.Type of Permit: (Check only one box on line A. Complete Ihre B if applicable) <br /> A. Q(New System y El Replacement System ❑ Treatment/Holding Tani:Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision 0 Change of Plumber 0 Permit Transfer io New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> �IyV.Type of POWTS stem/Com onent/Device: Check all that a 1 <br /> [d�Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ Al-Cmde ❑Maned>24 in.of suitable soil ❑ Mound<24 in.of suitable sail <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Ills ersal/I'reatment Arealnformation: _ <br /> Design Flow(gpd) Design Soil Application Rale(gpdsi) Dispersal Area RequQed(sf) Dispersal Area Proposed(at) Systepm Elevation <br /> 3 0 5 6 00 (a mo sj,2. O <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallon Unita =1 <br /> New Tar&- Rnmag Tanks U� tsa„ <br /> d: U' in <br /> Septic or Holding Tank Gan <br /> losing Chamber o eov I flCef W X <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> '' Bn MP/MPRSNumber 8usineesPhamNumber <br /> tle--el �.�N rC./t / '� <br /> ZZ <br /> Plumber's Address(Street'City,State,Zip Code) <br /> 7 70 a Alw y 3S Gv..GS s f,ri lily r— 5185'? <br /> VIII.Count /De arlment Use Od <br /> Approved ❑Disapproved Permit Fee Date Issued issuing t lure <br /> a sK t <br /> ❑Owner Given Reason for Denial -,y Lj., jp ,2fv I <br /> DC.Conditions of Approval/Reasons for Disapproval <br /> Atbrh m eomplete plansfor tis system and submit m the County only on paper not hem thin a 1a x 11 Inches in sift <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />