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commercemi.gov Safety and Buildings Division County�7 L <br /> 201 W.Washington Ave.,P.O.Box 7162 �(7 u r n it 77- <br /> iseonsin Madison,WI 53707-7162 Sanitary Permit Number to bc£dled in by Co.) <br /> oepartmerrt of Commerce 5.2 Z 9 j \1 <br /> Stale Transaction Number �./� <br /> Sanitary Permit Application Uj <br /> In accordance with s.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental ( (07 70 -Pe�rbto>, �ta' QP N[G <br /> unit is requited prior to obtaining a sanitary permit. Note: Application furs for stale-owned POINTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Q <br /> purposes in accordance with the PrivacyLaw,s.15.04(1)(m),Stats. 70 3 6,Id SfP r �Cl <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Paroel# <br /> InaNIL �• /Ge <br /> Property Owner's Mailing Address �,/ Property Location <br /> d 19 7 syrq n Fa ^O� ry✓C Govt.Lot <br /> City,State;? Zip Code Phone Number / %, Section <br /> -3J73 (circleone <br /> T'�D N; R /r1' E o(k <br /> IL Type of Building(check all that apply) Lot# <br /> Subdivision Name <br /> ES 1 or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑PubLc/Commercial-Describe,Use El city of <br /> CSM Number ❑ Village of <br /> ElState Owned-Describe Use ry SCa 7�. <br /> V"'l0, Pr Jam.0 16 Town of <br /> HL Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> A' ❑ Tramment/Holdin 8 Y (explain) <br /> ❑New System ;CI Replacement System g Tank Replacement Only Other Modification to Existing System(e lain) <br /> Lill Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑ Permit Revision ElChange of Plumber ElPermit Transfer to New <br /> Before Expiation Owner <br /> ,W.T e of POWte <br /> TS S sm/Com onent/Device: Check all that apply) <br /> O Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ Al-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 ersaVTreatment Area Information: <br /> Design Flow unuo Design Soil Application Rate(gpdsf) Dispersal Area Requhed(at) Dispersal Area Proposed(at) System Elevation <br /> J oo . 7 `fd 7 1 43.t- S3. ra <br /> Vl.Tank Info Capacity in Total #of Manufacturer n <br /> Gallo. Gallons Units U $ a <br /> New Tanks Existing Tates <br /> 41. U yr m y [W C7 d <br /> Septic or Bolding Tank 7�0 '70G <br /> Dosing Chamhr J O O SO6 <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> C2 rG�L /TO �Cr n s 715- �6�0'///.S`7 <br /> Plumber's Address(S lCity,State,Zip Code) <br /> 0(7760 Ie- 3S Lr/G6yrev c✓1 �Y�93 <br /> VIII.Cotta /De artment Use On <br /> ly <br /> Date Issued I im Signature <br /> kf Approved ❑Disapproved❑ Owner Given Re <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plana fm the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />