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eommereeml.gov Safety and Buildings Division County7 <br /> 201 W.Washington Ave.,P.O.Box 7162 fj u r n p 7`� <br /> tisconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co,) <br /> Department of commerce //&'3 <br /> Sanitary Permit Application State Tramo.tom Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental /V//A <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if differenl 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,a.15.04(1)(m),Stats. ,�^^T� <br /> L Application Information-Please Print All lnfot 111 ,kh .3C / A119, /-/Gklee C1 13/- <br /> Property Owner's Name Parcel# <br /> 00p) C h 034 1521 07500 <br /> Property Owner's Mailing;;��Address Property Location <br /> l3 bis 0 Sut Gr GoA Lot <br /> City,State Zip Code Phmne Number <br /> 17O SCM O k r t` �Al SS'O(p g %.,_'/.(circle on <br /> (ot# - 3rl,l - 4/ g(o T 37 N; R /,fvc1E<11 <br /> RI or <br /> of Building(check all that apply) 9 Lot# <br /> R7 1 or 2 Family Dwelling-Number of Bedrooms .C,. Subdivision Name <br /> Block# <br /> ❑PubbrlCommemial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of ( `1 <br /> Town of rec df i 0.&a' U� <br /> IIL Type of Permit: (Check only one box on lime A. Complete line B if applicable) " <br /> A. ❑New System y Replacement System ❑TreatmrnUHolding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Pemtit Renewal El Permit Revision El Change of Plumber ❑Perm¢Transfer to New Lial Previous Permit Number and Date Issued <br /> Before Expiration owner <br /> IV.T eof POWTS S stem/Com onent/Device: JCbeck all that apply) <br /> Nan-Pracenrized In- mund ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 is of suitable soil ❑ Mound<24 in of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Di ersalfrreahnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(af) Dispersal Area Proposed(at) System Elevation <br /> 300 — <br /> V1.Tank Wo Capacity in Total #of Manufacturer <br /> Gallo. Gallo. Units <br /> New TanksExisting T-ka <br /> y 3 Je <br /> w� a <br /> Septics Holding Tank 3080 =OGO <br /> S�Gu N <br /> Dosing Chamber <br /> VII.Responsibility Statement-L the undersigned,assume responsibility for installation oflhe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> RI C./C 111"'01e',, -5 /��.P .� 4A. gr l 715= � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776D tv-e53 f rNl sy8 3 <br /> VIIL Cour /De "latent Use Oral <br /> Approved ❑Disapproved Permit Fee "Com" A" <br /> ure <br /> ❑ Owner Given Reason for Denial $3-.509 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> its ( a5 B✓a.+sfeal Fine Sawe�rlvam: SS4 8. 1b wpEra� calf rs evaG6k. <br /> Attach to es plele pans for the sysnm avd submit b the CouWy only am paper rot tea Ibao s in s 11 IorM in she <br /> SBD-6398(R.01/07)Valid tbru 01/09 <br />