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comRlerce.wl.9ov Safety and Buildings Division County //�� <br /> 201 W. Washington Ave, P.O. Box 7162 C 41r� <br /> I'� M ibnsin Madison,W1 53707-7162 <br /> Sanitary Permit Number(to be filled in by Co.) <br /> apart Ent of Commerce <br /> Sanitary Permit Application State Transaction Number w <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental jK,j74z <br /> unit Is required prior to obtaining a sanitary permit Note Application 1'omts fur stale-owned POWTS are Project Address(if ditTerent than mailing address) <br /> !+'• I fabd ted to <br /> trk Dep6nment of Commerce, Personal Information you provide may be used fir secondary xV <br /> u ses'{n acaordanc with the Privacylaw,s IS 04 I m,Stats. �b PM� 7O <br /> 1. A lication Information-Please Print All Information 7f <br /> Prop lYy Owner's Name Parcel# 0 7-00 <br /> a fier�/ �6 Sv/;-j 1-1 (5CJ-exact-o�1/S/ <br /> '7o c) _ <br /> Property Owner's Mailing Address / Property Location Jam/ <br /> q ! 0 Govt.Lot <br /> City,State "Lip Code Phone Number SC y, � LA) �p Section <br /> crrcleonc <br /> I 3Y N; R� Fr4W <br /> 11.Type of Building(check all that apply) <br /> IA;or <br /> q <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ <br /> - City of — <br /> —_ - <br /> ❑SlateOwnal-Describe Use � CSM Number L1 Village of <br /> 141 Iyp of ftirmitl Check only one box on line A. Complete line B if applicable) <br /> A <br /> (] New Syste Replacement System ❑lYcmmenlMolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Trans'(cr to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> { "�• I 'i °tb of bW1l5 System/Component/Device: Check all that apply) <br /> 1111 0Nn-Presaunzed lln�nrrkCround ❑ Pressurized In-Gruund ❑ At-Grade AMound_24 in.ofsuitablcsuil 11 Mound<24 in.of suitable soil <br /> El Iding'I'ank lJ Other Dispersal Component(explain) _ ❑Prettealment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required ooDispyersal Area 0 Proposed(so System Elevation <br /> y�ts / � 99" Y <br /> VI.Tank Info Capacity in Total P of Manufacturer <br /> Gallons Gallons Units s m o o <br /> Ncw Tanks <br /> Existing ranks <br /> ScpticorH - <br /> Dosing Chamber <br /> V 11. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW I'S shown on the attached plans. <br /> Plumber's Name(I'nn}j Plumber's SlinnUtu I MP/MFRS Number Business Phone Number <br /> Plumber's Addlcss(Street,City,SWtc,lip Code) <br /> r <br /> VIII,C tint eta imam Use Only <br /> Permit Fee Date E."I Lssuing Arent Signature <br /> A{�proved ❑ l7isappmvcd <br /> ❑Owner Given Reason for Denial 5g <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans fur the system and submit to the C unto nNy on paper not less than 9.112 s I I inches in sit <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />