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cornmeree.Wl.gov Safety and Buildings Division County <br /> ( <br /> 201 W.Washington Ave.,P.O.Box 7162 QuV n P fF <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 5,910&5 <br /> Sanitary Permit Application State Ttamaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm Code,submission of this form W the appropriate governmental <br /> unit is required prior W obtaining a sanitary permit Note: Application forts for state-owned POWTS arc Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> ptuposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> p <br /> LApplication Information-Please Print AB Informix 7077 RAA IAeW L.asaf <br /> Property Owner's Name Parcel# 61.20 9380 0/Z00 <br /> R'*"4)rn Hwen (.. 07 ole Ave /aie s-/ar (.ri 014000 <br /> Property Owner's Mailing Address Prop"Location <br /> N7o / Q/o;sdell 9.,r Govt Lot <br /> City,State Zip Code Drone Number <br /> IYy Y., Section /L <br /> M lJ `YIN, STy/9 &1A- e%J,IF- S'}Kai (cycle one) <br /> IL Type of Building(check all that apply) Lot# T 40 N; R /6 E or® <br /> ®1 or 2 Family Dwelling-Number ofHedromes 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number a❑a Village of <br /> CJ Town of 0-Ite/Ah at' <br /> Ill.Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> ®New system 0 Replacement System ❑Treatment/Holding Tank Relacemmt Only ❑ Other Modification to Existing System(aPlain) <br /> B. ❑Permit Renewal ❑Pmmit Revision ❑ Change of Plumber ❑PermitTrawsfa to New List Previous Permit Number and Data Issued <br /> Before Expiration Own" <br /> N.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ®Nm-Pressurized In-Ground ❑Pressurized hi-Ground ❑At-Grade ❑Mound>24 m of auitabi soil ❑Mound<24 in.ofauitable soil <br /> ❑Holding Tank ❑0th"Dispmal Component(explain) ❑Prebeatmmt Device(explain) <br /> V.DispeirsaYrresumeast Arm Information: <br /> Design Flow(gpd) Design Soil Applicaaioo Rste(gpdet) Dispersal Area Required(et) Dispersal Area Proposed(at) System Elevation <br /> 300 . 7 4,4 9 I 4sa I 'FAf. 7�1 93, 7 <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gations Gallows Unita y Tvi ,y <br /> New Tasks Tixeting Tanks <br /> b <br /> s <br /> Septic or Holding Tank 7S0 7S10 <br /> Dosing Chamber -roo S`00 <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumb"'s Name(Print) Plumber's Signature MP/Iv1PRS Number Business Phone Number <br /> Rie-le 1/0 k/n t I P64,A,%a 74 ,tets8sI 44r7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 76 0 Alw 3.t t r/-e bs fav Gtl2� Sv 893 <br /> VII Coon /De artment Use Only <br /> Approved ❑DisapprovedPmnitFce Date Issued Issuing Signature <br /> a 2 u <br /> O Owner Given ReasonforDrnvl 3�� 1 XTmte 0� <br /> IX.Conditions of Approval/Remom for Disapproval <br /> Attach W rnmpkfe plan for the system and=limit W the Court ady an paper rot has than a 1a x 11 halm W sin <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />