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Oommerce.Wl.gov Safe y and Buildings Division County <br /> 201 W.A ashington Ave.,P.O.Box 7162 B"r n Q 7� <br /> i seo n sn M ison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> In <br /> 1)apanmem W Gwtu4jq9 441 <br /> Sanitary Permit Application State Tranasction Number <br /> In accordance with a.Comm.83 21(2),Wis.Adm Code,submission of I fis form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Now: Applicat on forma for state-owned POWTS are Project Adiheas(if different Wan mailing address) <br /> submitted to the Department of Commerce. Personal infomution you provide may be wed for secondary <br /> purpos in ac xudance with the Privacy Law,a.15. 1 m),Stats. n <br /> L Applilciation Information-Please Print All Information <br /> Property Owner's Name// Rtrh1A t`la6L.60 144wKWSoU- 1I Parcel# Olt-9/30- 0/700 <br /> RIc1L a- Ileleh Wike- A1KE tKE 1 07-0/ -,2.40-15-01-5 /5.851.017 <br /> Property Owner's Mailing Address -J� /} Property Lnrztion <br /> ,i43 SY/ S • sL� on l 310 Govt Lot <br /> City,State Zip Code Phone Number yy Y., Section <br /> tach one) <br /> Forest La/c ; N sSOJ� 6s/ 'W'el- �1/4s T 40, N; R � Eo <br /> IIL Type of Building(check all that apply) Lot# <br /> IJ l or 2 Family Dwelling-Number of Bedroom '7 Subdivision Name <br /> Block wt i-IFE s01 mC s <br /> O Pubbc/Commereial-Describe Use O City of, <br /> 11 State Owned-Describe Use CSM Number ❑Village of <br /> Town of '4&k&O'7 <br /> Ill.Type of Permit: (Check only ona box on Une A. Coamplel r line B if applimble) <br /> A. LYN.System ❑Replacement System O Treadmien Molding Tank Replacwcnt Only O Other Modification to Existing System(explain) <br /> B. O Permit Renewal O Permit Revision O Change of Plumber O PermitTransfer m New Lot Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS sbera/Consonent/Device: Check all hat apply) <br /> La Non-Pressurized In{'round O Pressurized In-Ground OAt-Gade O Moand>2A in.of suitable soil O Mound<24 in.of suitable soil <br /> OHolding Tank OOther Dispersal Component(explabr) O Prdreatmeot Devise(caplawl <br /> V.Dls ersaYnrnsimrout Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdat) Dispcs ud Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> use "1 41a Cvg sf.s-/ s/. <br /> VI.Tsak Info Capacity in Total #of Manufacturer <br /> Gallons Gallon Units y V w <br /> New Tanks Existing Tanks .4 s 7 <br /> Septic or HoWvg Ts& <br /> Dosing Clamber <br /> VIL Responsibility Statemmt-1,the undersigned,assume respo isibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signal= NUTAIPRS Nuiliber Business Phone Number <br /> Rue% //o gins <br /> Plumber's Address(Strut,City,State,Zip Cade) <br /> 7760 �-y 3S lt/ebslr�r SH�93 <br /> VIIL Coun /De artmmt Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Signa <br /> S �j - p OO 7 <br /> ❑Owner Given Reason for Denial 'R 2- //IRI L rd <br /> DL Conditions of Apps vsd/Ressoths for Disapproval <br /> Atbcb W complete plans for the system and ibmftasthe County onlyan paper not 1.than a in sll inehn in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />