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commerce.wl.gov Safety and Buildings Division Coun / / <br /> 201 W. Washington Ave., P.O. Box 7162 nl <br /> isco ns i n Madison,WI 53707-7162 Sannary Permit Number(to be filled in by Co.) <br /> Department of Commerce 53 a a W <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned Project Address(if different than mailing address) <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stars. ���� <br /> I. Application Information-Please Print All Information /r(,� NC <br /> Property Owner's Name �i (� Parcel# (p7O,?OA .2 y0 / 0 <br /> ON d QS q,#3 7S -15' /6- frw 05-41,144 <br /> Property Owner's Ma iling Address Property Location <br /> 3 a vf oao-gl35 05-q00 <br /> Govt. Lot <br /> City,State Zi Code Phone Number 7 <br /> Zip n 'b,_ 'b,Sec[ion <br /> Q - G V�i/ ,j rj/O ��"9 (circle one) <br /> II. T e of Building(cher all that apply) Lot# T b a R�_E o19 <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms YV Subdivision Name <br /> // Q C <br /> Block# P d 9'A) s ei eI- /6/1/ <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ElState Owned-Describe Use SM Nu <br /> Cmber El Village of <br /> 5r-Town of <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ;[ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement OnlY ❑ Other Modification[o Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision K Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) <br /> I-Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Raw(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 30D f �{� q z/sa 3.S <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o <br /> New Tanks Existing Tanks c " u <br /> 0 <br /> a` U v, vi w U a <br /> Septic or mils&--n- 7.5-0 1 <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber's Signa lure MP/MPRS Number Business Phone Number <br /> �l r.�� z z�69/ <br /> Plumber's Address(Street ,City,State,Zip Code) of <br /> Q o X S/ -5/1- e, 5 _V <br /> V II. County/Department Use Only <br /> Approved El Disapproved Permit Fee Date(Is'sued Issu(i�ng A�g�en�[Signature <br /> / <br /> ElOwner Given Reason for Denial S -5b. �1��(�.h <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> SBD-6398 (R. 02/09)Valid thru 02/11 <br />