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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 /3k p pleP, <br /> tiScons i n Madisom Wl 53707-7162 Sanitary Pe mi( umbe (nto be filled in by Co) <br /> Department of Commerce bS <br /> Sanitary Permit Application stateIransactionNumbere <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form/o the appropriate$ovemmrntal <br /> unit is required prior to obtaining a sanitary permit. Note: Application fors for stzteowned POWTS are Project Address(if in <br /> than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> p!Mscs in accordance with the Privac Law,a.15.04(1)(m),Slats. c <br /> I. A lication Information-Please Print All Information / 76q Ew Ae Lk doh <br /> Property Owner's Name <br /> Parcel# <br /> atM<r►J zbthdrn 03d $d35/ 01 yoo <br /> Property Owner's Mailing Address Property Location <br /> �� O �✓'t�en LflnY <br /> City,State Zip Code Phone Number Rt- 1'/ <br /> /`r tYq SyV Ya, Section_ <br /> G�dC h 17+.faf Loh SS'3l7 9SJ A �8 y747 (circle one) <br /> IL T of ntmaju check a6 that apply) Lot q T�N; R /S E-15V <br /> Type g( PP Y) <br /> ®1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> PubadCommercial-Dweribe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM—Number El <br /> ❑ Village of <br /> V•g / //0 LYpTOWnof .SWrds <br /> HL Type of Permit: (Check only one box on line A. Complete line B B applicable) <br /> t7 New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit RevisioneofPlber Gat Previous Peril Numberand Date Issued <br /> Before Expiration ("hang um ❑Permit Transfer to New <br /> Owner <br /> TV.Type of POWTS stem/Com menVElevice: Check all that appy) <br /> aNon-Presamized In-Ground ❑Pressurized In-Ground ❑ Al-Grade ❑Mound 124 in.of suitable sod ❑Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) . <br /> V.Dispersal/Treatment Area Information[: <br /> Design View(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(all D7IMbanufactumer <br /> l Area Proposed(at) System Elevation <br /> } ai ° • -7 Y�.6 zi".>d <br /> VI.Tank Info Capacity in Total #of <br /> Gallons Gainers Unita yG c o <br /> New 7F gaistirg Tmrks u U <br /> b W $ <br /> Septics Holding rank 76Y14'3" 4/ppp ad7p <br /> Dosing Chamber <br /> VII.Resp0=b(Bily Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans, <br /> Plumber's Name(prom <br /> t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> tai a Ic lel,,,.l <br /> Plumber's Address(Street,City,State,Zip Cade) <br /> j77`0 ,y,.. 3S Liredsfr� w� 54 ? <br /> V II.Cour /De "talent Use Ont <br /> Approved ❑Disapproved Permit Fee Date Issued Iaeum gent Signature <br /> � ,� a <br /> ❑Owner Givrn Reason for Denial <br /> IX.Conditions of Appr isir"easons for Disapproval <br /> �a ,( <br /> eP&(' taI9A I$ at ra) coMpav�n,aaE 7l)0+30a ' 1000(r4//ry <br /> Atmeh to eomplete plamfor the aptem and subuR to the Courcy oNy m paper mt Ins than 8 in x 11 Inches io size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />