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i <br /> i <br /> P-quired <br /> meree.wi.gov Safety and Buildings Division County <br /> n 201 W.Washington Ave,P.O.Box 7162 .6u v e f f <br /> ,Wisconsin Madison,W1 53707-7162 SunitaryP it Numbs (m be filled nby Co.) <br /> nt of Cona serve 444&a <br /> Sanitary Permit Application State Tmma 'un Number <br /> m.83.2t(2),Wis.Adm Code,submission of this form to the <br /> obtain a sanitary appropriate governmmfal \f/ <br /> submitted to the W �Y persalt Note: Application forme For elite-owned POWTS are project Ad a(if different than mailing address) <br /> Department of Commerce. Personal information you provide may be used for secondary <br /> ass in accordance with the Priv Law,s.15. 1 m),Stats. A <br /> I. A Baum Information <br /> -Please Print All Wormation d 9,3 �l DA e/n Ler <br /> Property Owner's Name <br /> Pa cel N <br /> �wve /la l6�ck o� 7/OD <br /> Property Owner's Mailing Address <br /> le /ars/ <br /> Property en <br /> City,State Zip Code Phone Number Govt Lot <br /> New Melt re.e a�P L✓1� r seetim ! 9 <br /> 7 7/5-38/- 3JSS le me) <br /> rrlyyL Type of Building(check all that aP)dY) Lot q T YD R /5r E m6 <br /> Prior 2 Family Dwelling-Nombe it drooms • Subdivisien N e <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑Cityaf <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Ar Town of <br /> IIL Type o(Permit: (Check only one box m lime A. Complete tine B if applicable) <br /> A ❑New System .�RcPlacemout System ❑Treatment/Holding Tank RepLcemmt Only ❑Other Mo ' tion m Exiatm S fem <br /> B Ys (explain) <br /> R ❑Peruit Renewal ❑permit R <br /> Expiration <br /> evin eofPlumber 0hermit LietPreviom it Number and Date Geued <br /> Tnmfa to New <br /> Owner <br /> ryIV.T of POWT3 taJCom menHDevice: Checlt aU tbet a 1 <br /> ea.Nen-Prmauraed In-Ground ❑Pra surized ba-Ground []At-Gnde ❑Mound->24 in.of suitable soil ❑Mound<24 of suitabie soil <br /> ❑Holding Tank ❑OtherDispersal eumpunent(explain) <br /> ❑Pretreatment Device(explain) <br /> V. et'sa1/I'mmamt Area WormaBm• <br /> Design Flow(gpd) Deign Soil Appllemml Rate(gpdaf) Dispersal Area Required(at) Disposal Area Pm <br /> (as0 Per* Posed(et) System Elevatiun <br /> ' 7 6 44 -3 bv8 S3. O <br /> VL Tank Wo Capacity in Total N of Manufacturer <br /> Gallons Gallon Units 3 0 <br /> New Tucks Existing Tadd <br /> Septic or Holding Tank <br /> /OOO /000 S/c r.w <br /> Dosing r-3em4r <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown an the attad ed plans. <br /> Plumber's Name(Pelri//m) Plumber's Signature <br /> Beninese Phone Number <br /> Plumber's Address(Street,City,State,Zip Cade) 7 <br /> 77,6D /mow 3S <br /> VIIL Coun /De artmmt Use Unl <br /> Approved ❑Disapproved Permit FF�ee DLate I'�s7ued I.umgbAgem Si�ratum <br /> ❑Owner Given Reason for Denial $ <br /> � <br /> IX.Cmdlum of ApprovaUReasms for Disapproval /moi <br /> Athch b osmpkfe plum far the system acrd mbmR m th C^assY ae4y m paper eat lea ih®g 1rs a 11 Ircha m <br /> SBD-6398(R.01/07)Valid thio 01/09 <br />