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commerceml.gov N C0MPWF NE-D Count' �? <br /> 201 W.Washington Ave.,P.O.Box 7162 V k NN e <br /> ' f i sco n s i n Madison-WI 53707 7162 Sits Pnmit Number(to be filled in by Co.) <br /> me <br /> D"mrtrrt of Commanerce 10 2 C <br /> Sanitary Permit Application State Tramaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental ^�- <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-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 /> purposes in accordance with the Privacy Law,a.15.04(1)m),Slats. �Q /'�r,V•f! <br /> I. A Bforsn <br /> c ttion lnation-Please Print An Informationr✓ <br /> Property Owner's Name Parcel# <br /> Lori Vomwa(� <br /> Properly Owner's Mailing Address Property Location <br /> /Ob Gra /brae- NE Govt.Lot <br /> City,State Zip Code Phone Number _ YA - Y., Section <br /> E/ in Al SS 173 A (circle one <br /> T (Carole <br /> N; R E <br /> ,ILL T of Building(check all that apply) 1 Lot# <br /> /-S— o <br /> l0 1 or 2 Family Dwelling-Number of Bedrooms 04 Subdivision Name <br /> Block# wildh(c Abw as <br /> ❑PublidCommercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSMNumber El village of T <br /> Q�Town of �/-'/�Jeax <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, pI rSNew System Replacement System 0 Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. 0 I'ermil Renewal ❑Permit Revision ❑Chang- fPlumber ❑PermLL Transfer to New <br /> List Previous Permit Number and Date hutted <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> krNon-Preasurized In-Ground 0 Pressurized In-Ground 0 At-Cmde ❑Mound>24 in.of.citable soil 0 Mound<24 in,ofsuitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispenaVrmahnont Arm Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Arm Proposed(at) System Elevation <br /> 30v .7 4t.5 "Y 3A 93. o <br /> VL Tank Info Capacity in Total I #of Manufacturer <br /> Ganom Gallon Units o v <br /> New Tanks Existing Tanks m 8 o a <br /> Septic or Holding Tank 8BO �CO <br /> Ibsirig Chamber <br /> VII.Rmponsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature WIMPRS Number Bminesa Phone Number <br /> RIC/c /So /c," f /.,e. /� ol/s�s-/ >/s 8lrc- y/rT <br /> Plumber'.Address(Street,City,State,Zip Code) <br /> / 7760 /S/. r 3� /rJe6sfpr full S �f�4� <br /> VIIL Court /De artramt Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued //�� Innis (Signature <br /> ❑Owner Given Reason for Denial �j '73 (]U <br /> IX.Conditions of Apprtaval/Reas ens for Disapproval <br /> Attach to couplets plans for the systess and mbah tothe County edy e s paper net Ina than a to x 11 Inches In she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />