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� i <br /> corrnflerots.wl.gov Safety and Build ngs Division Con'"201 W.Washington Ave.,P.O.Box 7162trilo <br /> nC�' Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> 54031Z � <br /> Sanitary Permit Application SoleTr/T��mosmoon/Numb. <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form o the appropriate govemmenol (/can£y kevi eui <br /> unit is required prior to obtaining a sanitary permit. Note: Application forma for ante-owned POWTS are Project Address(if different Wan mailing address) <br /> submitted in the Department of Commerce. Personal information you provide may be used fer secondary <br /> Pumosca in accordance with the Privacy Law,s.15. 1 m Stats. <br /> I. Application Information-Please Print AN Information ✓wn� <br /> T7 <br /> 1 / Parol# <br /> Pr"ertyO7 N S�IA(t{^I (lUr S /��Su{�e Acre5c(" 436- 5�0?5-43ooa <br /> Property Owner's Marling Address r-rvuo Property Location <br /> 7950 ✓/loco Za Ke Rd, Govt.I'm � <br /> City,State Zip Code Phone Number <br /> l{Jelasfr 4JL S'�8I3 7i5-966—f13/7 0'� %, mcicon o25 <br /> � ) <br /> D.Type of Building(cheek all that apply) Lot# T�N; R E m W <br /> ❑1 or 2 Family Dwelling-Number of Bedmomv Subdivision Name <br /> Block# <br /> ■Public/Commercial-Describe Use d uj <br /> ❑City of <br /> ❑Stan/Tuned-Describe Use CSM Number ❑Village of qq � <br /> 0 Town of (.LYI I 0 A/ <br /> D[.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑New System <br /> It Replacement System ■TreatmtmUHoNing Tank Replacemepc Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Phmlxr ❑Permit Transfer to New Lin Previous Permit Number and Dao Issued <br /> Before Expansion Owner <br /> IV. of POWTS S m/Cor nent/Device: Check all that apply) <br /> ❑Non-Pressurized In-Gmmd ❑PreSSUff—d hi- irmmd ❑At-Dade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ■Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispermnircotment Area Information: <br /> gm FlowDesign Soil Application Raw(gpdst) Dispersal Area (sf) Dispmsal Arra proposed(s0 System Elevation <br /> l55`� ILIA- / NIA- Nk <br /> VI.Tank Info Capacity in Tool #of Manufacturer <br /> Gallons Gallons Units <br /> o $ v <br /> New Took. Existing inks O <br /> V <br /> a in rn w C7 W <br /> Septic or Bokbog Tank OQps ^�� (�•�r r <br /> Dosing(hember V fN <br /> VII.Responsibility Statement-I,the amieleraipted,aoawe ropomidbillly for imtaBatbn of ted POWIN shorn loo the nthched plass. <br /> Pllmber's Name(Print) Plumber's Sigoatine MP/MPRSNumber Business phone Number <br /> 41o �re �o �2 Ybd6�c/ <br /> Plumber's Address(Steer,City,State, <br /> STo lSdd <br /> ) 1CL !,GleOl �+ �oW �7t1o1 <br /> .Coon emit Use Only <br /> Approved ❑Disapproved Permit FeeDate Issued Issuing <br /> S <br /> ❑Owner Given ReasonforDenial 375-1 .23.z-ur 2oJ0 <br /> IX.Conditions of Approval/Itemons for Disapproval <br /> Atoch to complete plow for the syatem and submit in the County only on paper ant leis than 8 in x 11 Inches its rise <br /> SBD-6398(R.02/09)Valid thin 02/11 <br /> JUN 2ZP01V0 <br /> BuRN� COUM-M, <br />