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Commerce.Wl.gov Safety and Buildings Division County .,y <br /> 201 W.Washington Ave.,P.O.Box 7162 /3tA✓n e I 1 <br /> 4L f i sco n s i n Madison.Wl $3707-7162 SanitaryPelmil Number(to be Filled in by Co.) <br /> Oetaartmem of Commerce <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 /> unit is required prior to obtaining a sanitary permit. Now: 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 n <br /> purposes in accordance with the PrivacyLaw,s.15.04(1)(m),Slats. ���,//^ /(I /ACJ L/ ,^ <br /> 1. Application Information-Please Print All lnformatio I- N hANG R( AO <br /> Property Owner's Name Parcel#0]-O ot-A-41 h S-31-7 <br /> VA 111 en1'er 3`7 03- 000- 42!66,90 <br /> Property Owner's Mailing Address Property Location <br /> 5940 Minnow 4f4 Roo. carr Lu �dv<oF <br /> City,State Zip Code Phone Number Y, Section / <br /> L)12t,bo-r WS 5-If930 T�N; R 1S�cleone )_ <br /> IL Type of 'ding(check all that apply) Lot# <br /> 91 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> 0 State Owned-Describe Use CSM Number D village of <br /> Vol It /73 Town of SW/u <br /> 111.Type of Permit: (Check only one box on line A. Complete tib <br /> line B if applicable) <br /> / — <br /> A. D New stem S lacement System System Rep y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Petmit Renewal ❑Permit Revision <br /> ❑Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com anent/Device: Check all that apply) <br /> A Noo-Pressurized In-Ground D Pressurized In-Ground 0 At-Grade 0 Mound>24 in of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersalfrmabnerut Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 4S0 . 7 (943 1 69S? iSo .a? <br /> VL Tank Wo Capacity in Total #of mmaacturer <br /> Gallons Gallons Units wo <br /> New I.&. ExisRng Tanks $i <br /> b a a <br /> got '5 h � wc7 a <br /> Septic or Holding I.* /al S-0 <br /> Id so <br /> Ib"Chemhr <br /> VII.Responsibilky Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /L/e /lr'gS / � />' as SSS/ lis-866-qi•S`7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 /-/w Y 35- Lt/QS.t71rr wi- <br /> Vll Ccun /De artment Use Only <br /> Ji(Appm ❑Disapproved PermitFce Date Issued y., Issuing Iglutum <br /> ❑Owner Givm Reason forl�iat S �/e+U IJ JVAG (}J)� s <br /> IX.Conditions of Apprwal/Reasona for Disapproval <br /> Attach to complete plans forth system and wheat to the Camay only an paper not lea than a to x Il inches N alar <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />