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Co111111Cr'C6.WI.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 y/'Ave 7'Y <br /> rsconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> tDepulltinand of merce <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 <br /> 14(O 783 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if diffxent than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> Purposes in accordance with the Privacy Law,s. 15.04(l m,Stars. <br /> I. Application In(fo/rm�ation-Please PrCint All Information 65� <br /> � ^r�W A) n <br /> o>4 <br /> Property Owner's Name Parcel#n1J <br /> ©/5,/ DS o oc7 <br /> Property Owner's Mailin Address Property Location <br /> / O / , /q'" Govt.Lot <br /> City,State Zip Code Phone Number / Section <br /> js �30 eircleon <br /> / e <br /> T_K7_N; REo� <br /> 11.Type of Building(check all that apply) Lot# <br /> P`I-m 2 Family Dwelling-Number of Bedrooms_ / Subdivision Name <br /> C <br /> Block# <br /> ❑PublidCommercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> i� ` Town of F <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System lacement System ❑ Trea[mem/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision L1 Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade AMound>24 in.of suitable soil ❑ Mound a 24 in,of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis rsal/I•reatment Area Information: <br /> Design Flow(spill Design Soil AprAcation Rate(gpdsf) Dispersal Area Required(et) Dispersal Area Proposed(at) System Elevation <br /> 3oa 3ev 3© a ��38 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'o <br /> New Tanks Existing Tanks u (J E v <br /> P o <br /> 6 U ti q ti i.0 3 W <br /> Septic or Holding Tank 7�Q <br /> Dosing Chamb. D <br /> VII.Responsibility Statement- 1,the undersigned,=nine responsibility for installation of the POWTS shown on the shacked plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ��Ade 4 ��/.�, zz76 e6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VII .ComAYADepartment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing en[S lure <br /> ❑ Owner Given Reason for Denial <br /> $ W D-7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system mid submit 0 the Cosaty nab on paperaot less Hina 8 in r 11 hwhea in size <br />