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commerce.wi.gov Safety and Buildings Division County <br /> 201 W. Washington Ave.,Y.O. Box 7162 <br /> isconsin Madison.W1 53707 7162 /-nJ - � <br /> Department of Commerce Sanitary Permit Number(to be filled in by Co.) <br /> Sanitary Permit Application State Transaction Number <br /> In accordance it s.Comm.83.21(2),Wis.Adm.Code,submisxion of This full,lu the appropriae govenmrntal <br /> unit is inquired prior to obtainin g a sanity <br /> b ry permit. Note: anon Application loons for slaleynvncJ PUW'1'S arc <br /> submitted to the Department of Commerce, Personal information ou (� ) <br /> ass in accordance with the Privac Law,s. 15.oy(l)(m),Slats. !'rojed Address(ifdilTerenl Than mailing address) <br /> y' provide may be used for sannJary <br /> I. A liwnr Information-please Print All Information 1' I <br /> Property Owner's Name aq �1�J�I S J <br /> Parce3 l 8 <br /> PrRA <br /> operly Owner's <br /> Property Location <br /> City,State -.V.. <br /> / Zi Code 1 Govt.Lot <br /> A)U// P-5 3 Ibonc Nunll+cr / <br /> /yl a, d a 3 1.._�.. Section <br /> IL Type of Building(check all that apply) Lot b -7 <br /> lairelc non <br /> f J— N; R /:5 _ Y o Wi <br /> ,V-ha 2 Family Dwelling-Numbnnerof Bedrooms rf <br /> --- SubskvieietrClamc <br /> D public/Cummcreial-Describe Use hDescribe Uxc <br /> _ _.._ _.. D City of <br /> State Owned-Describe Ilse CSM Number <br /> - ------ __ ❑ Village ul' �— t <br /> Va 9 f town of-- K__56 n.J <br /> f 11.Type of Permit: (Chcek only one box tin line,L Complete line R if app icable) <br /> 1. <br /> D New System ARcplaccancm Systcm D 'I'realmenUfloldin8'I'ank Rcplzcenlem Onl <br /> Y El other Modification to lixisling Nysten(explain) <br /> B. D Permit Renewal D Permit Revision <br /> ❑Change of l lumber <br /> Before Expiration D Permit'I I 11 to Nmv List Previous Permit Number and Date Issued <br /> Owner <br /> IV.T e of POWTS S stem/Cam ment/Device: Check all that apply) <br /> on-Pressurized In-Ground D pressurized In-Ground ❑ ,11-Grads D Mound 2d in of sortable soil ❑ Mound<23 in,of suitable soil <br /> ❑ Dolding Tank D Other Disposal Component(explain). _ - <br /> V.Dis ersaVfreamlent Area lnfornlafion: -- --- --- --- ❑'retreatment Device(cxpLlin)-___- <br /> Design Plow(Bpd) Design Soil Application Rate(gpJsl) Disposal:\rca <br /> 6O) Rcyuvcd(sl) Dispersal Area Proposed(at) System Elevation <br /> 7 <br /> VL Took Into ' Capacity in 4 '. <br /> lolal Ill' ManulSdurer <br /> Gallons Gallon. IInits <br /> u c <br /> Ncw'1'anks 13sisting'I'anks a .u. V <br /> tilptIC tY 1lsaaalg-11mk <br /> Dosing Chrmher O f�8 / <br /> VII. Responsibility Statement- 1,the undersigned,assume rrspoi sibilily for inmal'a0on I.rlha•PO\5"fS shown on Ihu allachnl plans. <br /> Plumber's Name(print) Plumber's Signature <br /> /N /� bR'.T1YRS Number '1 Mesa Phone Nnmbcrr <br /> `Y I.�s�din -✓ _ �z ��9/ .� Y�-7 6 <br /> Plumber's AJJress(Street,Illy,Slalc.%ip Code) <br /> C <br /> VIII.Chants/De arhnent Use Only - <br /> Approved ❑ Disapprove) Perm�iJt Pu o/1 Date Issued Issuing en nature <br /> ❑ Owner Given Reason for Denial Si(` � J57A �U1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atlacb to complete plum for tin ayrtcm arta rulxnit re thr County may on pvprr not le»than B trs x l l Incbra to size <br /> SBD-6398(R.01/07)Valid Ibnl01/(9 <br />