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eommerce.wi.gov Safety and Buildings Division Court <br /> 201 W.Washington Ave.,P.O. Box 7162 c,f <br /> /'► Madison WI 5 707— <br />`..�i.�'...,�.,,;..,. ,. ��W����� , 3 7162 Sanitary Permit Number(to be filled in by Co.) <br /> p Departlnl8nt of Commerce5403µl <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 183 a(o (7 <br /> unit is requited prior to obtaining a . . <br /> q p sanitary permit. Note: Application B I cation forms for <br /> rY P pp state-owned POWTS are <br /> Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> m oses in accordance with the Privacy Law,s. 15.04 I m,Stats. <br /> 1. Application Information-Please Print All Information 0/.�3 US <br /> Property Owner's Name '1 Parcel 0-7_ D 0 6 <br /> Property Owner's Mailing Address Property Location 16G1 <br /> '86 S Govl.Lot <br /> City,State 1 Zip Code Phone Number /p <br /> G'r ,�fs4H/ Gtr SySyo 671V 68 —.�29ya /V (circlSection <br /> e one <br /> 11.Type of Building(chec all that apply) ��77 Lot tt <br /> c TN; RL�eonsL <br /> 012 Family Dwelling -Numberof Bedrooms o _ Subdivision Name <br /> II Block# ^— <br /> ❑Public/iCom:tiercial L Describe Use <br /> ' El city of _ <br /> ❑State Owned-Describe Use '—" CSM Number ❑ Village or <br /> -�. OTown of �,�"o re—/ <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> ,A, :.:. n: �} <br /> ❑�N'ew System replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of'Plumber List Previous Permit Number and Date Issued <br /> g El Transfer m New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 17 Mound>24 in.ofsuitabie soil Mound<24 in.ofsuitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Plow pd) Design Soil Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(st) System Elevation <br /> 3 �0 _3C_-)C5300 / 60 <br /> VI.Tank Into Capacity in Total #of Manufacturer <br /> Gallons Gallons Units uU a <br /> New Tanks Hxis[ing Tanks v J _ n V <br /> 0 <br /> a` V vt h in i O o. <br /> Septic or Heldiesy Tm,k 4)0 (D <br /> Dosing Chamber. J O �� O <br /> f VII.Responsibility�tatement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Gt /�o/ uS�i o�m aT z z 76 �l Y9 -7a <br /> Plumbers Address(Street,(-ity,State,Zip Code) <br /> r <br /> Vfl � o0n 7De ar[ment Use Only <br /> Approved [IDisapproved Permit Fee Dale Issuedqq-� Issuing Age azure <br /> El Owner Given Reason for Denial S 375 A,.,A?,, <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> D L � <br /> Attach to complete plans fur the srsn ns and submit to the County only on paper not less thaninches in size <br /> 8 <br /> AUG 1 S 2010 <br /> BURNETT-COU <br /> SBD-6398(R.02/09)Valid Brru 02/11 ZONING <br />