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eommeree.wi.gov Safety and Buildings Division County / <br /> 201 W. Washington Ave., P.O. Box X162 rt9'd' Y"j� <br /> ,�f i seons i n Madison,WI 53707-7162 Sanitary Permi Number(to be filled in by Co,) <br /> Dapertmem of Commerce <br /> Sanitary Permit Application Stare Transacli nNumber <br /> In accordance with s.Comm.83 21l Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Addre (ifdifferent than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 19 <br /> purposes in accordance with the Privacy Law,s. 15.04(1 m),Stats. <br /> 1. Application Information-Please Print All Information a _Z)a_ <br /> SDD <br /> Property Owner's Name parcel#0 0, v-a _ 3r�_s-.o3 <br /> �'rVI-� id 3 g 0_2,000-01 :>-600 <br /> Property Owner's Mailing Address p Property Localion <br /> f�S 7�-- C 1-ii V)- 1141-S4 10- Govt.Lot <br /> c ltn.statte,, ip Code Phone Number / / /� _`�� y, 1�y,, Section Z <br /> C VJJ�`I Ir KV 8;,;_1 15 Viz- 766Ai Z� ��rcle one <br /> T_1� R� E or� <br /> X11.Type of Building(check all that apply) Lot a <br /> V] I or 2 Family Dwelling-Number of Bedrooms Subdivision N me <br /> Block p <br /> ❑ <br /> Public/Commercial-Describe Use ❑City of <br /> CSM Number El Village of <br /> ❑ <br /> State Owned-IXscribe Use � // 1� _� <br /> Town of Q LIlto"I'K�- <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System ❑ Trea[menHoldingTank Replacement Only Other Mod fication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous I emit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> K,Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound< 4 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Desi n Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s System Elevation <br /> oo , - ((z 1/so 9.3 <br /> V1.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ` o N P. u s m n <br /> a U in H A ii U a. <br /> optic Holding Tank rx ViJ t) ')( <br /> sine cher X <br /> VII. Responsibility Statement- 1,the undenigne4 assume respO1113ilIffity for installation ofthe POW'I'S shown on the all ached plans. <br /> Plumber's Name(Print) Plu tier's Signature MP/MPRS Numbe Busiho <br /> ness Pne Number <br /> Nets u­e Y wr I u(7_7 2ZS22C( / 6 <br /> Plumber's U's ( <br /> Addrress(Street,City,State,Zip Co e) <br /> 7 ( V M <br /> Vlll ounty/De artment Use Only <br /> Peit Fee Date Issued Issuing nt nature <br /> Approved 11 Disapproved rmA110A110 .y <br /> El Owner Given Reason for Denial �/)� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> M Y 1 0 2007 <br /> SUM ETT COUNTY <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x I I mclo WNING <br />