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commerce.Wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 /aur n e H <br /> isconsin <br /> Madison.W1 53707 7162 Sanitary Peril Number(lo be tilled in by CoJ <br /> Department of Commerce ,5.2//33 <br /> Sanitary Permit Application State Transaction 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 fors for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purEses in accordance with the Privac Law,a,15.04(1)(m),Stats. <br /> 1. Application Information-Please Print AB inform ationt 1 <br /> 750 Stone 6,a <br /> nefr l?c� <br /> Property Owner's Name Parcel H <br /> Duanr /Ze.Se`rber 0110 4333 - CAS'o0 <br /> Property Owner's Mailing Address Property Location <br /> 666' Sa //:vwn Zane jlt-E. z <br /> Cil State Gov[Lot <br /> Y. Zip Code Phone Number y '/., Section 33 <br /> L./<pobri y /ft /t?N $�fyd / 7b3- Sod - /330 (circleoneJ),., <br /> IL Type of Build' T y0 N; R /b E o4yJ <br /> yp tttg(check all that apply) Lot N <br /> ®Ior2Family Dwelling–NumberofBedrooms_ 3 I Subdivision Name r `t <br /> V�`JJ <br /> ❑Publie/Commercial–Describe UseBlock B, — <br /> ❑ City of <br /> State Owned-Describe Use CSM Number ❑ Village of <br /> J. as P � I PrT,,n of Q14/e'I6 nes/ <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System �y <br /> y aq Replacement System ❑ Treatment/Holding Tank Replacement Only L1 Other Modification to Existing System(explain) <br /> B. ❑ Pernit Renewal ❑Peru Revision ❑ Change of Plumber ❑Peril Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POW TSS stem/Com onent/Device: jCheck all that apply) <br /> Nan-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Requeed(af) Dispersal Area Proposed(sf) Sys[con Elevation <br /> y.5'0 , S Se o go a <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °' c <br /> New Tanks Existing Tanks <br /> Septic a Holding Tank <br /> ---Ne O Iso <br /> Dosing Chamber <br /> VII.Responsibility 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 Business Phone Number <br /> R rc& f10 /c," 2�- 0(14 15-JI-S-1 -71s-S66- 'Y/s-7 <br /> Plumber's Address(Street,city,State,Zip Code) <br /> X7760 f/ 3S �f/ Gbs <er Lv� 5893 <br /> VIIL Coun /De artment Use Ont <br /> Approved El Disapproved Permit Pee Date lssue/d Q Issuing Agent S' <br /> ❑Owner Given Reason for Denial <br /> $30o� /� OtO 08 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plass for the system and submit to the County only on paper not less than 9 in x Il inches in sire <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />