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ON COMPUTERISCANNFn <br /> commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave,P.O.Box 7162 /3(,t N A ,oft <br /> isco n s i n <br /> Madison,WI 53707 7162 Sanitary Permit Number(to be filed in by Co.) <br /> Department of Commerce ,55 11 5C) <br /> Sanitary Permit Application State Trmn.c/on N.ber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form m the appropriate governmental .+'G Reolt j <br /> unit is required prior to obtaining a sanitary permit Note: Application fors 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 /> Lwm.cs in accordance with the Privacy Law,s.15."1)(m),Slats. /_f-� �j J I(�. <br /> I. A Bcation Information-Please Print All Information (! U "Ot <br /> Property Owner's Name Parcel#(eg&y: oJp�f3/$oZ$oD <br /> N10,e /c A Fria X35 a 07-020-2 -4 om 0 a <br /> Property Owner's Mailing Address Property Location <br /> "P0 4;0)r Govt Lot <br /> City,State Zip Code Phone Number SC y, SE Yq Section /S <br /> - <br /> c <br /> tt/ SSaos 9 Gsf -�7/ -S4?4 (crcleone <br /> ILr Type of Building(check all that apply) qQ Lot# T N; R /(O E <br /> tXt or 2 Family Dwelling-Number of Bedrooms d, Subdivision Name <br /> Block# <br /> ❑Public/Commereial-Describe Use <br /> ❑ City of <br /> El State Owned-Describe Use CSM Number ❑Village of <br /> r�Town of 0-k/4,N &(. <br /> Il L Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑Treatment/liolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Prn A Number and Date Issued <br /> Before Expiration Owner <br /> � <br /> IV-/.T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> �-/ <br /> tS Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable sail <br /> ❑Hording Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> =Flow <br /> nent Area Information: <br /> Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(al) System Elevation <br /> 17 yA 97 471301 mss. 90 <br /> VL Tank Info Capacity in Tout #of Manufacturer <br /> Gallon Gallons Units <br /> New Tanks ExistlM Tanks <br /> a <br /> �r <br /> Septics HoldingTmJr `�� 711 � ..J�/f- W ,� <br /> Dosng Chamber O <br /> VII.Respotlsibill Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> MP/MPRS Number Business Phone Number <br /> /Zrc/c /�a /Crs 1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -;;(;e) .</4... <br /> VIII.Cour /De srtment use Ont <br /> Approved ❑Disapproved Per2il Fee {{gy�pp Date Issued ��rr�� IasuingA tore <br /> ❑Owner Given Reason for Denial S 3.G.�J'SAO .?�rj eSL .cvl� <br /> TX.Conditions of ApprovaUReasons for Disapproval � " � <br /> Sat( 74aQ3 ltta(LG3Ee 383 G - MAHfbMED 1 �OAH/ SAND, constf6i.t� tvr><!t Spr /ragvt 0-r+ �[; <br /> D L� <br /> Aaaa4s to complete plain for the syafem and submit to the CouNy only an paper not leas than a 12: ta size <br /> SBD-6398(R.01/07)Valid tivu 01/09 AUG 2 4 2011 <br /> SURNErr <br /> ZONINGUNTM <br />