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commereemi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 &r <br /> s eo n s i n Madisom WI 53707-7162 Sanitary Peon <br /> It i mlt Number(to be filled is by Co) <br /> Department of Commerce `l <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 W obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(ifdifferenl 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,s.15.04(1)(m),Slats. C/ / /IIJJ�II <br /> L Application ln[ormation—Please Print All Information r��J r (,� , I <br /> Property(Tuner's Name �} Parcel# <br /> 7,-4m .QPn �iazr -f' ,W �� Ud6 - 43 / 9-o1-,90 / <br /> Property Owner's Mailing Address p �'� Property Location <br /> '?o /� GO "ss�f U Gee-Lot <br /> City,State Zip Code Phone Number SE Y., N 1✓ Yq Section /9 <br /> W e bs t or�1 �`��� 3 (cotta one <br /> //� o�ll <br /> rrlLt Type of Building(check all that apply) Lot# T N; R�E <br /> Al l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑PublieCommercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> .®Town of Oa/L4 r+es'� <br /> Ill.Type of Permit: (Check only one box on lime A. Complete line B if applicable) <br /> A. ❑New System y �Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑Chan a of Plumber List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permi[Revision g ❑Permi[Transferm New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> WNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.ofsuitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treahnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 3 ° p '7 ti/5 4`7s 11 90. 0 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ro'$ v <br /> New Took. Gv am 9 Tanks o V u ab p <br /> ci;U rn m in w C7 M <br /> Septic or Holding Tank 8 Q <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPINWRS Number Business Phone Number <br /> ;�/ 16 /70 /c/, S �7�i t� �/ ��sBS/ 7/s=tfG6- 9/S7 <br /> Plumber's Address(Street,Ciq,State,Zip Code) <br /> 7F0 /-mow 3S G/edS<e✓ �/� S�f� T <br /> VIII.county/De artment Use Ont <br /> raved ❑Disapproved Prnnrt FFeee� Date Issued Issuin Agent Signature, <br /> ❑Owner Given Reason for Denial S— � 0 11 02 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete Alam for the system and submit to the County only on paper not less than 8 in x 11 inches issue <br /> SBD-6398(R.01/07)Valid thty 01/09 <br />