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ON COMPUTER/SCANNED <br /> eommememl.gov Safety and Buildings Division County, <br /> 201 W.Washington Ave,P.O.Box 7162 �c i^n e <br /> ly- <br /> iseo n s i n Madison,WI 53707-7162 Sanitzry P.it Number(m be filled in by Co.) <br /> Department of cc�vrvss ` <br /> Sanitary Permit Application State Tamacbm Number <br /> In accordance with e.Comm.83.21(2),Wm.Adm.Code,submission of this form to the appropriate govanmeoral <br /> unit is required prior to obtaining a sanitary panni. Note: Application forms fm state-owned POWTS are Project Address(if dillercet&;mailingaddrm) <br /> submated to the Department of Commerce. Personal information you provide may be wed for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1 m Stab. OV a r•�Art Tis/Y <br /> L A liatim Worseatim-Please Print All Information <br /> Fropeny Owner's Name Parcel 8 <br /> TernY La / ."i 1, <br /> See, aqaJ)4 <br /> Property Owner's Mailing Address Property Location <br /> I5421 N OP-t e{L.r,1 GovL Lot <br /> Cay,Stat Zip Code Phone Number Y,, Ye, Section it 3 <br /> ROOK-A' IkIJ '55:30:3 cchnbom <br /> TL Type of Building(check all dust apply) Lot M T 40 N; R /3`E u& <br /> ®lcr2Family Dwelling-Number ofBedmow 3 79 90 r/ Subdivision Name <br /> Blore 0vevlri«d. A44t--La VV <br /> ❑Public/Commereol-Describe Use <br /> ❑City of <br /> ❑Stat Owned-Describe Um CSM Number ❑Viu geef <br /> Town of ..ALc,kM r1 <br /> TIL Type of Permit: (Check only one box m lane A. Complete fine B if applicable) <br /> A. PfNew System ❑Replacement System ❑TresteacmHolding Talc <br /> Replacem®t Only ❑OWaModa"uation to I:sistiYB System(explain) <br /> B. ❑Permit Renewal ❑Perna Reviion ❑ Change ofPl®bar I ❑Pana Transfer to New Lint Previeru PermaNumber and Dat Issued <br /> Befom Eapcation Owns <br /> IV.Type of POWN System/Component/Device: Check all that apply) <br /> — <br /> qNao-w=sur&wa-Gmmmd ❑Preumirsd l>fGrouud ❑A4Caade ❑mound2:24in.ofmaabksor7 ❑Mound<24in.ofauitabiesoil <br /> ❑Holding Talc ❑Olher Dispersal Component(explant) ❑Pretreatment Device(explain) <br /> V. aVTleatment Area Wormatim• <br /> Design Flow(gpd) Design Soil Application RaWZpdef) Dispersal Am Requved(at) Dispersal Arca proposed(at) System Elevation <br /> 'ISO . 7 643 1 641e 91•Sa <br /> VL Tank htfo capacity in Total 8 of Manufacturer 9 <br /> Gallons Gallon Utas e p <br /> New Tanks Em sWgtatlrs <br /> 1z 3 <br /> Septic or Holding Tads /66'0 <br /> Dosang0mater <br /> VIL Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans <br /> Plumber's Name(Print) Plu/nm�b��ees signature '/ MFMMS Number Business P unc Number <br /> Pei /LlL p 1Lrn.d /e.e.,e sa� /T` d I(S 8S / 7/S rwi&s— elIs,7 <br /> Plumber's Addis(Sttat,City,State,Zip Code) <br /> of 7760 w y 3S— I-Ve-Asfrf ZvS S'S�d5 <br /> rVIIL Come /De ortment Use Only Z/ <br /> lFl Appmvad ❑Diupproved n tFac Grp Date Wand ��/ haunt igmtre <br /> ❑Owner Gives P..for Denial S`{4�!/ �.19r" / <br /> DL Conditions of Appr al/Remoms for Diaapprwal <br /> Atbehteeampleh plem froths ayshm d submitis the Cmely dy en paper not leas tbo a In III inch=t ane <br /> SBD-6398(R.01/07)Valid thru 01109 . <br />