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COmmercemi.gov Safety and Buildings Division County ? <br /> , 201 W.Washington Ave.,P.O.Box 7162 /,J to r rl t <br /> i s co n s i n Madison.Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce .551 1 .2 <br /> Sanitary Permit Application StateT tion Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Cade,submission of this form to the appropriate govemmemal tM-( eco ICr.t2 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forma for state-owned POW]S are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary l <br /> purposes vh accordance with the Privacy Law,s.15. 1 (m),Slats, LOY'�brSt.h "� <br /> I. Application Information—Please Print All Information ,{� <br /> Property Owner's Name <br /> Parcel#_6 7-b 3 4-jl-//O--/57-7 G- <br /> 13eb Paw/no /5'-5'77-e9.1.000 <br /> Property Owner's Mailing Address Property Location <br /> 4'G9P ok49fk p.{ ,vE Govt.Lot <br /> City,State Zip Code one Number Y, Yy Section 3 6 <br /> 'T! yy. ircle one <br /> _.7 f /" Al SsG�{0 T �0 N; R J 7 E or� <br /> IL Type of Building(check a6 that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms -1 ) ,Z Subdivision Name <br /> Block# 1'1 hC5 <br /> ❑PubkdCovunercial-Describe Use <br /> Z t�-a�• Osteal ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> Town of LIN/On <br /> III.Type of Permit: (Check only one boa on Ikte A. Complete line B if applicable) <br /> A. El9�a. <br /> New System t, Repincemrnl System ❑ Treatmrnt/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change ofPlumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owsoyr <br /> W.Type of POWTS S stem/Com mtent/Device: Check aU that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V'Dis ersahTreatzn t Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requir (sf) Dispersal Area Proposed(st) System Elevation <br /> So <br /> . 7 <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Unita o cO <br /> New Tanks Faceting T-k. <br /> y g b g m <br /> dU y � rn WC7 ?L <br /> JE <br /> Septic or Holding Tank <br /> Dosing Clamber 60 GG` / <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/Iv1PRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ol 7 760 Xl &v a GS)`c✓ <br /> .V 111.Cour /De artm <br /> Ieent Use Onl <br /> Approved ❑Disapproved Pannit Fee Dare Issued Issuing A ignature <br /> a YY q�� <br /> ❑Owner Given Reason for Denial 3 26 .0911 ,9O <br /> IX.Conditions of Approvao,xeaaons for Disapproval <br /> Attach to complete plans for the system and aubatt to the Comsty anly m paper sort less than 8 to a 11 rarhes last. <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />