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commereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 /34 e e fit- <br /> ' f i seo n s i n N Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Departmard of Commerce 53 Z;Z 55 <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 ,4- kvi cw <br /> unit is required prior to obtaining a sanitary permit Now: 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 usedfor secondary <br /> purposes in accordance with the Priv Law,a.15. 1 m,Stats. <br /> 1. Application Information-Please Print All btfOrmation 4781 Warner /CA 4d <br /> Property Owner's Name Parcel# <br /> Ghar/sf krAAeb- o/v- d"4 -ek 700 <br /> Property Owner's Mailing Address property Locative A:4,17 r U V6l A 20 <br /> I!Y 8 r1 k/.e rn a v Z/- lFee. Gest Lot 6 <br /> City,State Zip Code Phone Number <br /> Y., Y., Section W <br /> tv2b6 � <br /> fib-4.1 t. S" S4d43 7/S34 <br /> - 3H9-,U ((cycle one) <br /> IL Type of Building(check all that apply) Lot# T N; R /S E ore t�1� <br /> �1or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Namef L r Lo1 ,y <br /> Block# 17' OT 6D✓ 6 EX <br /> ❑Public/Commereial-Describe Use <br /> ❑Cityof <br /> ❑State Owned-Descnbe Use CSM Number ❑ Vin geof <br /> Town of Le. >o11eWe <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System 16 Replacement system ❑ Troament/Hoiding Tank <br /> Replacement Only ❑Other Modificative to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision <br /> ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS tem/Com anent/Device: Check all that apply) <br /> R Non-Pressurized In-Ground ❑Preasurized loGromd ❑ At-Grade ❑ Mored>1A in of suitable soil ❑Momd<24 in.ofsuitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Prctreatment Device(explain) <br /> V.Disptwsalffreatmesat Ares Infamatim: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required(at) Dispersal Ares Proposed(at) System Elevation <br /> HSO 5— 9DD 900 <br /> VL Tank Info Capacity in Total #of Manufacturer y <br /> o t <br /> Gallons Gal- I y ° F0 <br /> New Tanks Existing Tsds B 1 - o <br /> '.n <br /> Septic or Holding Tank FOOD /Ise <br /> Ibdng Chamber I I so go <br /> 600 1 1 600 <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown an the attached plana. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> I -le //0 k ow- -/ > <br /> Plumber's Address(Street,City,State,Zip Code) <br /> at -7 u-e6 r7'rr <br /> VILL Cour /De artmmt use Only <br /> Approved ❑Disapproved Perm2it Fxm D/atee(Issued( Issuurg rgmture <br /> ❑Owner Given Reason for Denial S✓a(✓� �` N"la✓GN 191 <br /> DC.Conditions of Apprvval/Remmu;fa Disapproval <br /> Attach to complete plantar the system and submit tothe County ady an paper ret has than a 14 x 11 Inches Issue <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />