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commeree.wl.gov Safety and Buildings Division County/n/ <br /> 201 W.Washington Ave.,P.O.Box 7162 U (' <br /> tilseonsin Madison.W1 $$707-7162 Sanitary permi Numb"(to be filled in by Co.) <br /> Department of Commerce ,'490,+q+I Q , <br /> Sanitary Permit Application State Tnneacti nNumber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit u required prior to obtaining a sanitary permit. Note: Application torsos for state-owned POWTS are Project Addrea (if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> sea in aocordwce with the Privacy Law,s.15.04(t)(m),Slats. <br /> 1. AllpficationInformation-PleasePrintAllInformation AW&> ,2144Y 67 <br /> Property Owner's Name Parcel k 018 2fD27C0 <br /> -o/8•Z 3D3 avb <br /> Property Owner'sMailing Addrwo7 9-/G-2f <br /> e Property I.ocali <br /> Aar 6 / .4CI i 51TSA &X. <br /> City,Stale Zip Code Phone Number list- 9RV, 9X M D6v— <br /> N <br /> I l / / „�L✓ '/., Y., Section d <br /> g cy (circle one <br /> IL Type of Building(check an that apply) Lot p T l_.L N; AX_E or�V <br /> ort Family Dwelling-Number of Bedroom. Subdivision Na e <br /> Block k <br /> ❑Pubtim <br /> c/Comeroial-Describe Use ^� <br /> 0 City of _.. <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> V <br /> i4-Town of <br /> I1L Type of Permit: (Check only one box no line A. Complete Rne 8 if applies e) <br /> A. eco System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Mmdifilion to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision 0 Change of Plumber 0 Permit Transfer to New Liet Previous P it Number and Dale Issued <br /> Before Expiration Owns. <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> Non-Pmsu,ized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound 124 in.of suitable soil 0 Mound 124 .of suitable soil <br /> 0 Holding Tank 0 011ier Dispersal Component(explain)___ _ _ ❑Pretreatment Device <br /> V.Dis ersaVI mahnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdsf) Dispersal (sl) Dispersal Area Proposed(at) System Elevation <br /> 3 0 6 laR6a v � O <br /> VI.Tank Info Capacity in 'Total q of Manufacturer <br /> Gallons Gallons Units <br /> Ex <br /> New Tanks isting Tanks U b 8 <br /> �u m <br /> Sepuca ypLhrg T- '- dO� l_ <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation ofthe POWTS shown on the an plans. <br /> Plumber's Name(Print Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) K71 15 <br /> VIICounty/Department Use Only <br /> Approved ❑ Disapproved ^� Date Issued Issum g ignalure <br /> er <br /> ❑OwnGiven Reason for Denial A0 o?�? b <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Cs,u P�o�, r s�17 PM-�Ec <br /> Attach to complete pare for the system aM submit to the County oNy on Aper rwt les than a Irz z Il IscMa yr a e <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />