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ON COMPUTER/SCANNED <br /> connnerce.Wi.gov Safety and Buildings Division County <br /> Wisconsin <br /> n 201 W.Washington Ave.,P.O.Box 7162 rp.7 tt e n e ff <br /> i sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to he filled in by CO.) <br /> Department Of Commerce -540 <br /> 36&/ J <br /> Sanitary Permit Application State Traros-�Ftion Number <br /> In accordance with s.Comm.8321(2),Wis.Adm.Code,submission of this form to the appropriate governmental 7 9?"&.'; —ry� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Deparunrnl of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15.04(12 m,Stater. p� <br /> I. A Bcationlnformlll <br /> ation-PleasePrintAnformation ��.� DQIVE <br /> Property Owcer'a Name <br /> Parcel#07-G:10.2•Mo•//•2;}•S O5•QO/•daLde <br /> 7m ztCms✓ . Og0 5'3d3 - O <br /> PropSOO <br /> erty Owna'e Mailing Address Property Location <br /> /90dS Z,pE%en way <br /> 1 <br /> City,State Zip Code Phone Number Got.Lot <br /> Y., Y., Section 3 <br /> 4. let v;(/'e /f1/V SSO�/Z4 held. F//O d t 3 (circle one) <br /> IL Type of Building(check all that apply) Let# T '/0 N; R /6 E or(!9 <br /> 19�1 or 2 Family Dwelling_Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSMNumb" ❑Village of <br /> V, 9 ? Town of Of K/arnd <br /> IIL Type of Permit: (Check only one box an lime A. Complete line B if applicable) V <br /> TB.fore <br /> New System ❑Replacement System ❑Trestment/Holding Tank Replacement Wy ❑ Other Mod cation m Existing System(explain) <br /> emtit Renewal ❑PermitRevision ❑Change of Plumber ❑Permit Transfer to New List Prcvio a Permit Number and Date Issued <br /> Expiation Owner <br /> ,IV.T e of POWT3 S stem/Com onent/Device: Check aft that apply) <br /> I81 Non-Pressurized In-Ground ❑pressurized le-Ground ❑ At-Grade ❑Mound>24 in,of suitable sod ❑ Mound<2q is of suitable soil <br /> ❑Holding Tank ❑Otha Dispersal Component(explain) ❑Pretrestmrnt Device(explain) <br /> V. ersalfrreatineat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdet) Dispersal Area Requved(d) Dispersal Area Proposed(sf) System Elevation <br /> q So I . 7 643 <br /> 6vs� S/. o <br /> VL Tank Info Capacity in Tonl #of Manufacturer <br /> Gallons Gallons Unita 6 <br /> New Tanks HxivWig Tanks Y 0 1 Y = <br /> fG U vi m rn9 i..,C7 P, <br /> Septic or Flokling Talc <br /> Doaag Clymer <br /> VII.Rpporrsibitity Statement-L the undersigned,mume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> MP/MFRS Number Business Phone Number <br /> /?/cic <br /> Plumber's Address(Street,City,State,ZIP Code) <br /> J7760 f< 3S W21J•J7ts/ Lt/1- �i 73 <br /> VI Cram /De ertment Use Only <br /> Approved ❑Disapproved PermnFm Date Issued Iasuin Signature <br /> ❑Owmer Givrn Reason for Drnlal S 3 <br /> LY.Conditions of Approval/Reasons for Disapproval <br /> Attach to wmplen phns fa ran system and who to the carroty aoly an pyer not km flan R!R z Il irclwa io siu <br /> SBD-6398(R.01/07)Valid tbrr 01/09 <br />