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eofnmeree.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 f n t f( <br /> i seo n s i W n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> oepartm ud of Commerce 5322 2` - <br /> Sanitary Permit Application TT�tion Number <br /> In accordance with a.Comm,83.21(2),Wis.Adm.Code,submission of this form governmental to the appropriate goveental Stat s L I&. � <br /> unit is inquired prior to obtaining a sanitary permit Note: Application forms for statc-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 <br /> PlEposes in accordance with the Privacy Law,s.15. 1 m),Stats. <br /> I. Application lnfirrmation-Plea7PAnt AElnformatio 4f3 .�ste-/n e pr. <br /> Property Owner's Name parcel# <br /> Sob ///e FFmAn 3 Da � Od8- 9/se - oProperty Owner's Mailing Address Property Location <br /> 7630 r v Gut Lot <br /> City,State Zip Code Phone Number 3 <br /> V, Y., Section <br /> m 11 /nN -17-4-41-7 9P (circle one <br /> IL Type of Building(eheck all that apply) 9 Int# T y0--N; R�E or <br /> ® Ior2Family Dwelling-NumberofBedmoms O' 7 g Subdivision Name <br /> ❑ <br /> Block# i(6r/ r- S1_ ItUK/�PmblidCommercul-Describe Use •/ GN <br /> L� ❑ City of <br /> State Owned-Describe Use CSM Number 0 village of <br /> R Town of sGp f� <br /> Ill.Type of Permit: (Check only one boor on line A. Complete line B if applicable)b <br /> A. 0 New System 19 Replacement System 0 Treatmcnt/Holdin Tank 70th"MndMffikatioa g Replacmral Only to Existing System(explain) <br /> B 0 Permit Renewal 0 Permit Revision ❑Change of Plumber 0permitTrawlertoNewnitNumberandDateIssuedBefore Expiration Owmr <3- <br /> N.T of POWT3 stem/Com onent/Device: Check all that a 8 <br /> 0 Nm-Presaur zod In-Ground ❑Pressurized In-Ground 0 At-Grade 0 Mound>21 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 15ff Holding Tank 0 Other Dispersal Component(explaim) ❑Pretruhoent Device(=plain) <br /> V.DispetzaI atm ent Arm Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Ares Proposed(sf) System Elevation <br /> VL Tank Info Capacity in Total #of Manufacmmr <br /> Gal ors Galloon Units .g o <br /> New Tanks E--Ii gT-b g <br /> n a w w til a <br /> selaw <br /> or Notdmg Tart: /a Se a•/Bro <br /> Ibrsig Cismher .I/00 � >r>�'/lira lto✓ }( <br /> VII.Rmport>dbility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana <br /> Plumber's Name(Print) Plumber's Signature 'i;UM 3 Number Business Axone Number <br /> /2/,/c f/eI /Z�a�..e0 /� �d�8s/ lir- X66- ell r7 <br /> Plumber's Address(Shat,City,State,Zip Code) <br /> 7760 .. -7s— W"sfr✓ wL SrfBr� <br /> VEIL Crum /De srtmen Use Oral <br /> Approved ❑Disapproved "it F. <br /> Date <br /> Is! d q Iuu' Signature <br /> ❑Owam Givm Reason for Denial 8 � f�� y j� �/ ` <br /> IX.Conditions of Approral/Reasom for Disapproval <br /> Attach to complete plains for the system and whet to the County only an paper not res therm a IR s 11 laches N she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />