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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 �u e r)H <br /> yf i soon s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Departmem of Commerce <br /> Sanitary Permit Application Stale Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental )59 ,9(907 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms 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 /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. nn <br /> I. Application Information-Please Print All Information )9y 9, C/a.JS town /2d. <br /> Property Owner's Name �$ Parcel N <br /> (//Y/0r"a A, V/4/C J -j OM/pl -dS,13 03,160 <br /> Property Owner's Mailing Address Properly Location <br /> x6d ' Govt Lot <br /> City,State Zip Code Phone Number <br /> ,SE '/., lE '/., Section ,13 <br /> 36 r/. /l/ 079.'0, circle one <br /> T 38 N; RAE o� <br /> IL Type of Building(check all that apply) Lot M <br /> I or 2 Family Dwelling-Number of Bedrooms a4 Subdivision Name <br /> Block H <br /> ❑Pubhc/Commereial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑t Villageof <br /> (`J Town of W 0 Ise/ C e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New S atom ❑Replacement System ❑ Treatment/Holdin Tank Replacement Only ❑ Other Modification to Existing System Y eP Y g eP Y 8 Y (explain) <br /> B. ElPermi[Renewal ❑ Permit Revision ❑ Change of Plumber 11PermitTransfer to New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com onent/Device: Check all that apply) <br /> ❑ Non-Pressurized tu-Ground ❑Pressurized In-Ground ❑ AI-Gmde ❑Mound>_24 m.of suitable soil -UMound<24 tu.ofsuitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersah'Freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdspersal Area Required(9f) Dispersal Area Proposed(at) System Elev <br /> t) Disation <br /> 300 . 9 3e7o 336 97. 06 <br /> V I.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units U ,R <br /> New Tanks Ewsting Taub '2 <br /> <� m <br /> ct U v, �' <br /> Septic or Holding Tank 7..$-6 7,$'O <br /> Dosing Chamber S.O 0 .SdB <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation afthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> e)dS6'1 lir - g66-vrr > <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 17768 t/r y 3S Lr�P�sf: Lv1 ��f 993 <br /> VIII. oun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date IssuedIssuin g ignabore <br /> S <br /> ❑ Owner Given Reason for Denial I]J/0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only m paper not less than 8I x 11 inches in siu <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />