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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 &vN'e <br /> iseo n s i n Madison,Wl 53707-7162 Sanita (Per/mit Number((to be fdlcd m by Co.) <br /> Department of Commerce NO 69 z <br /> Sanitary Permit Application State Transaction Number <br /> .l}� <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental /ig(p / <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stia"wned 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 r1 <br /> ece in accordance with the PrivacyLaw,a.15. 1 m,Stats. <br /> I. A tis im Information-Please Print AB Information <br /> Property Owner's NameP <br /> uce)# �J <br /> !Da lire Qrectiort 018- <br /> Property owner's Mailing Address Property Location <br /> Oats D;x&.7 D,: Govt Lot -3 <br /> city,State I ZipCode no Number Y., Y., Section <br /> rJ/0OniM fe en fh r7J s1r4L7/ T 39 N; R /b(circle <br /> e one) <br /> IL Type of Building(check all that apply) Lot# <br /> 19 1 or 2 Family Dwelling-Norther of Bedrooms Subdiviasm Name <br /> Black# <br /> ❑Publie/Commerciai-Describe Use <br /> ❑Cityof <br /> El State Owned-Describe use CSMNumbcr ❑vinageof <br /> ry <br /> IA Town of /YJe CNO H <br /> Ill.Type of Permit: (Check only none box m line A. Complete tine B if applicable) <br /> A. ❑New System .® <br /> ys Replacement System ❑Treamernf/HoWing TankRephc®rnt Only ❑Other Modification to Existing System(explain) <br /> B. ❑Parmit Renewal ❑Permit Revision ❑Change ofPl mbw ❑Permit Transferto New Liu Previous Permit Number and Date issued <br /> Before Expiration owns. <br /> IV. type of POW I'S System/Com mmt/DeAi . Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized in-Ground ❑ AbGmde ❑Mound>24 is of suitablesoil Q Mound<24 in.ofsuitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(captain) ❑Pretreatment Device(explain) <br /> V. . ersal/Freahnent Area Information: <br /> Deems Flow(gpd) Design Soil ApplicationRste(gpdaf) Dispersal Area Required(al) Dispersal Area Proposed(d) System Elevation <br /> 300 1 . 9 ,30o S.P-/ 9P 30 <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Galion Units o 0 <br /> a _ <br /> New TenksErdstisg Tanks <br /> d: U y ti ii c7 'a <br /> Septic or-Holding Tack A p0 <br /> Dating Chamber •7.$'•Q 71 ,� <br /> VIL Respoltsibility Statement-I,the undersigned,mature responsibility for installation of the POINTS shown on the attached plana <br /> Plumber's Name(Print) Plu'mber'ss signattuus, MgP/MPRS Number Business Phone Number <br /> J�(GIG �O /</HJ ��+f6� � �PJ��✓�J 7/.S- ?�6�0� v/J`� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> , 7760 N� �s ftied�r`er w7SY89P <br /> VIII Cam /De 7D=i..pp.7vd <br /> rtt Use Ont <br /> Approved ❑ Perm�iJt Fee Date Issued Issuing Sieature <br /> ❑ ason for Denial <br /> $ 300�° �� 07 <br /> IX.Conditions of Apprxwal/Reasorm for Disapproval <br /> Attach to cam plNs pure for the system and sobash to the County only m paper not leas than a r6 s it Inches In size <br /> SBD-6398(R.01/07)Valid ttru 01/09 <br />