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commereeml.gov Safety and Buildings Division County <br /> 201W.Washington Ave.,P.O.Box 7162 ,atee p.e - <br /> 'Wisconsin Madison.Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> epartment of Commuree 53212613 <br /> Sanitary Permit Application Stale TT!�!Jac1tion NDumber , <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (/W'1 C; <br /> unit is required prior to obtaining a sanitary permit Now: Application forms for ante-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 Q <br /> purposes in accordance with the Privacy Law,a.15. 1 m),Stats. /dH� GA <br /> L Application lnf ms tion-Please Print All htformatim <br /> Property Owrwr's Name Parcel#p 7-0at trap a-t -I OA- <br /> f rV 4P d- 04res .f/<q,/qa Y1 , I oho- D/eK 000 )2Dp <br /> Property Owner's Mailing Addmss Property Location OM 1,41.3 <br /> 0'"b"a" AA. / L a a+ t' eror�bt cauulL 4841*4 604 (flaim <br /> City,State Zip Code Phone NumberNNI11 I Yy )4F Y., Section <br /> C/+t4K bM /�, LD(�H (circle One) <br /> pIL Type of Building(check.all that apply) Lot g T L/0 N; R /rf E or ' <br /> P I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of a,, �,. <br /> I/. j O 7 3 9 Town of $e-y/' <br /> Ill.Type of Permit (Check only one box on lite A. Complete line B if applieable) <br /> A. New System ❑R lacemcm System ❑Trcatment/Holdin Tank <br /> M� ys cPB Replacement <br /> Only 11 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ e of Plumber List Previous Permit Number and Date Issued <br /> Chang ❑Permh Tranfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS tem/Com ent/Device: Check all that apply) <br /> P Non-Pressured In-Ground ❑Pressur zed In-Grouvd ❑ At-Dade ❑Momrd>24 in.of suitabh:soil ❑Mound<24 im ofauimble soil <br /> ❑Plolding Tani; ❑OtherDispersal Component(cxplam) ❑PreheatmeN Device(explain) <br /> V.DispersablFreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Ares Required(at) Dispersal Ares Proposed(sf) System Elevation <br /> ells-v -� 6 x: 6ys sy. '�n �a <br /> VL Tank Into Capacity in Toil #of Manufacturer <br /> Gallon Gaff. Units u e'g U <br /> New Tanks Existing Tanks I S y 027 <br /> C) to m 'w C5 i1 <br /> Septic or Holding Tank BaO 000 ✓�'/�• M... .� <br /> Dosing Chamber <br /> VIL Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the anached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MMS Number Business Phone Number <br /> /tic-/G J1e'ok-i'a 1 <br /> Plumber's Address(Street,City,State,Zip Code) ' , I <br /> 7740 /r"—' 3S- l/tl�W�Y✓ Lt7_T� .�/i��/ .3 <br /> VIIJ,Coun /De arfinent Use Only <br /> Approved ❑DisapprovedPersmlFx Date ued Issuing Sign <br /> ,t., <br /> ❑Owner Gwen Reaaon for Denial V/Wy J/ItIssgl(. <br /> IX.Conditions of Appr aUReasona for Disapproval <br /> Arachto sumpkle plan ror the system and submit as the County only an paper oat less Mae 9 M x 11 inches H Was <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />