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commercemhgov Safety and Buildings Division Comm <br /> 201 W.Washington Ave.,P.O.Box 7162 P. n Q <br /> isco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co,) <br /> Departmern of Commerce .SGJ 1 Z p elT <br /> y�r <br /> Sanitary Permit Application State Tr Numl� <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 forms for state-owned POINTS 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 /> purposes in accordance with the Privacy Law,a.15.04(1)(m),Stats. S 99d if G rt <br /> I. Application Information-Please Print All Information / O <br /> Property Owner's Name <br /> PmceIHo7 03d-A- 4NS-/9$ <br /> TCrr tai7'tran Oa{-cdo -es//000 <br /> er <br /> Property Own 's Mailing Address Property Location <br /> 7'Y1 1�'Orh r0 Cr-f-- t)evciht Ns'E of• <br /> Cii�tyy,,Stam Zip Code Phone Number c Q <br /> ip <br /> //rOYf �B I// l/1/.� J �r 7S-J. ) <br /> — ,5f—. Yq 6f/� CVCE oto one rcp// <br /> II.Type of BadT N; R /ding(check all that aPP1Y) ? Lot N <br /> 1 or 2 Family Dwelling-Number of Bedrooms J Subdivision Name <br /> QcttES <br /> ❑Pubbm <br /> cJComercial-Describe Use Block# 'LV"Ch's <br /> ❑City of <br /> El State Owned-Describe Use CSMNumber El Village of <br /> Pq Town of SW 1 S d <br /> I1L Type of Permit: (Check only one boa on line A. Complete fine B if applicable) _ _ <br /> A IM y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only -. <br /> New System g ep Other Modification to ExistingSystem y stem <br /> (explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Pemsit Nuber and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com ent/Device: Check all that apply) <br /> ®Non-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 ersaUTreahnenit Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdet) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> /!SO 7 43 lov8' 89.0 <br /> VI.Tank htfo Capacity in Total #of Manufacturer <br /> Galloon Gallons Unita c$ <br /> New Tanks <br /> Exahng Tanks <br /> Septic aHolding Tank JBeQ /O SO � Sk.s1 ti/ <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Rini) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /c/c <br /> Pluber's Address(Street,City,State,Zip Code) v/s` <br /> dt7?64 3S— W e✓s10 ye>� Srf� 93 <br /> VIII.Cour /De artment Use Only <br /> Approved ❑Disapproved Permit Fee y�' Date Issued Issuing Ag igna <br /> ❑Owner Given Reason for Denial $ `J�,>-'(7/aJ 2< c- 2OII <br /> IX.Conditims of ApprovaL`Reaaorm for Disapproval <br /> Atbch to couplets plans for the ryatem ab ncbuH orbs County ady on peer not h n than 8 in a 11 inches in size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />