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eommereeml.gov Safety and Buildings Division Co <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> ti seo n s i n Madison,WI 53707-7162 San7;15,5 <br /> tary P nit Number(to be filed in by Co.) <br /> Dnperttr�Mo«rnn,arce 7B 530 <br /> Sanitary Permit Application State Trans ction Norther <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental / T 1715 W <br /> unit is required prior to obtaining a sanitary permit Note: Application forts for stato-owned POWTS are Project Add ess(if different than mailing address) 91` <br /> submitted to the Department of Commerce. Personal information you provide my be used for secondary <br /> Main <br /> em m <br /> in accordance with the PrivacyLaw,a.15. b <br /> 1 m),Sta . �� Y <br /> I. A titiam Information-Please Print AN Information <br /> Property Owner's Name Parcel# 5 <br /> DIAgs 5 uu 3 018 03 0 foo U <br /> Properly Owner's Mailing Addteee Property Lo union <br /> 1011 Q Pt Govt Lot <br /> City,State 11..,, Zip Code <br /> � �Phone Number A I Y '/y section <br /> y?�3 <br /> wewrca W\ "� "+"13 1K. OoIOb' `MIOS T 3q N; R I�O( EoE}/ <br /> IL Type of Building(dterk all that apply) Lot# <br /> X1 or 2 Family Dwelling-Number of Bedroom I1-. ( Subdivision Name <br /> Block# <br /> ❑PublidCommacial-Dab.Use <br /> ❑ City of <br /> 11 State Owned-Ikscn3te Use CSMNumbcr 11 Town <br /> village <br /> W�I ' ��I Jy Town o GCNL� <br /> III.Type of Permit: (Check only one box on Ikre A. Complete tine B if app& le) <br /> A. ).ryew Syst. ❑Replacement Sy <br /> arem ❑ Treaboent/Holding Tack Replacement Only ❑Other N&dificatw to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Pmvi Permit Number and Date Issued <br /> Befine Expnation Owner <br /> IV.Type of POWTS S stem/Com ent/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized Io-Ground ❑ At-Grade XMmmd>24 m of suitable soil ❑ Mord 24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(expla' ) <br /> V. reatment Arm Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispeoal Area Required(at) Dispersal Area Proposed(i System Elevation <br /> 16ou I J -0 1%00 MOS <br /> VL Tank Indo Capacity in Total #of Manufacturer <br /> Gallons Gallons Unit °e <br /> 3 <br /> New Tmdrs &Fisting Teaks U y w <br /> A.a , IW io <br /> Septic or Holding Tad 375o 37So 3 <br /> Dom%Climber 1250 ITTO I 1 <br /> VIL Itesponaibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the a Rached plans. <br /> flumher's Name(Pint) Plumber's Sigmztem MP/MPRs Nund er Business Phone Number <br /> fe 2Z$8S1 ?ls 8E6 S <br /> umber's Address(Sheet,City,State,Zip Code) <br /> z <br /> VI LCoon /De arhaea Userant <br /> Approved ❑Disapproved Permit Fee Dateissued luuh Signstmre <br /> ❑Owner Given Reawnfm Denial $ 300 Ro Jav1¢ O7 <br /> DC Conditims of ApprovaUReasmns for Disapproval <br /> Attach to enaphle phnsfar the rys4m and suhah to th Coudy a dr an paper was W thes 8 FR a it inch Inane <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> it <br />