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CoRIRIerBeml.gov Safety and Buildings Division County <br /> 4961,'Wisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 6,rr1 <br /> i soon s i n Madison,WI 53707-7162 Sanitary�[P,,ermit Numb"(to be filled in by Co.) <br /> Dapartmern of Commerce / / / )O <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.53.21(2),Wis.Adm.Code,submission of this form to the appropriate govwereen l <br /> unit is required prior to obtaining a sanitary permit Note: Application fomrs for stateowned POWTS are Project Address(if different than mailing address) <br /> submitted.to the Department of Comm,,,. Personal information you provide may be wed for secondary <br /> purposes n accordance with the Privacy Law,a.15. 1 m,Stats. (- <br /> L Application Wormation-Please Print AB information 'ol 701301 E, !]C�,/J �/i /�/ T <br /> Property Owner's Name Parcel H <br /> a� bio _ 9/aa - c 3 moo <br /> Properly GWner's Mailing Address property Location <br /> /!� Z Sfl� St• S.E. Govt.Lot <br /> City,State Zip Code Phone Number <br /> i'y Yy Section 34 <br /> /✓/ /t /N/V. J�S�!/rf 41'l- 379-1SS6 (circle one <br /> r1 Type of Building(check all that apply) Lot g T 40 N; R /g,' E o <br /> p l or 2 Family Dwelling-Number of Bedroom ✓• + - Subdivision Name <br /> Block <br /> ❑PubadCommereial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V. g f. )1 c)-, <br /> �Tnwnnf sale/<�d <br /> III.Type of Permit: (Check only orae ho:on Ibre A. Complete fin B if applicable) <br /> A. ❑New System ❑ <br /> ye Replacement System Rr Treatment/Holding Tack Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑permit Revision ❑ ChmgeofPlumba ❑Permit Trawferto New List Previous PermitNumber and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onenl/Device: Check all that apply) <br /> /D <br /> ❑Non-Pressurized InLround ❑Pressurized In-Ground ❑At-Grade ❑Mwnd>24 in.of suitable soil ❑ Mound c 24 inof suits le soil <br /> ❑Holding Tank ❑Olha Dupenal Component(explain) ❑Pretreatment Device(explain) <br /> V. ' ensaVrroabnent Area Wormatio n: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> .�?O OST/a,(s 7G, <br /> VI.Tank Wo Capacity in Total Hof Mamdacturer <br /> Gallons Gagnon Units ggyg <br /> New Tanks Exa, Tarks Q U 99tt b .� <br /> SepRcaHoiding Tads <br /> Dosng amn <br /> 00 <br /> VII.RCsIonsibiIty Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plms. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Nnmba 7Busincss Phone Number <br /> RG l� e let, s lael //4 <br /> Plumber's Address(Street,City,state,zip code) <br /> 7 d � 3S' /i//��tS�r✓ /it/_r � �9� <br /> VIIL nun /De artment Use fad <br /> Approved Disapproved Permit Fee Date Issued/ Issuing tore <br /> ❑Owna Given Ressoa for Denial 5 � �/ 1fz147 <br /> IX.Conditions of Approval/Remens for Disapproval <br /> ExrST•� t�N+nopsi-o rs $6c-r-w GL.ay ,C6Nss Anno /}p -r <br /> n rI& /-655 1-94A) 2'f" of Eb6rr�a/ly �ft17dt rrL 0C Se-1 err Ftmei 'Cf- LV, e <br /> Attaeh to complete plans for the system and abdt to the Courtly only on papa out has than a in s 11 inch"in sire <br /> SBD-6395(R.01/07)Valid thru 01/09 <br />