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eommeree.wi.gov Safety and Buildings Division County �{� (�� <br /> 201 W. Washington Ave., P.O. Box 7162 sk riilt le 1 " <br /> iseonsi n Madison, W1 53707-7162 Sanitary Permit Number(to be filled in by Co,) <br /> Department of Commerce 5 <br /> 2 I Q2, <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s Comm.83.21(2).WIa. Adm.Code,submission of this form to the appropriate governmental 153 4o 4P 3 <br /> unit is required prior to obtaining a sanitary permit. Note. Application forms for state-owned POWTS are Project Address(if different mailing address) <br /> submitted to the Department of Commerce. Personal information You provide may be used for se dary <br /> purposes in accordance with the Privac Law,s. 15.04(1)(m),Stats. /n r/ P 7 U <br /> Application lication Information—Please Print All Information V 7 SoV- ! <br /> Propem Owner's Name Parcel# <br /> Vii I tr���ran Clturrf�t GFso�� 2 Oo(o -� l�-OSS�bo <br /> Propem r <br /> ^nOwnes ailin¢Address �l Propem Location <br /> V S7�t'xe' /�- 70 <br /> Govt.Lot <br /> Cit,'.State Zip Code Phone Number / <br /> � � 77 ,` �wCJ/S /., .Section � <br /> S Orel, .�T �7� 7� - 2271 T 3O N, R I7(circle on� <br /> Il.Type of Building(check all that apply) Lot# <br /> ❑ for 2 Family Dwelling—Number of Bedrooms / Subdivision Name <br /> Block# <br /> ❑ Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of � <br /> Vl 'P // 7T^1 <br /> Town of ,LtHIelS <br /> 111. Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ❑ New System Replacement System ❑ TreatmentMolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> e. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV. Type of POWTS System/Component/Device: (Check all that a 1 <br /> ❑ 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. Dis ersalrfreatment Area Information: <br /> Den Flow(gpd) Design Soil Application Rate(gpdsO Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 'LOb l ro Do 600 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> a u <br /> New Tanks Existing Tanks U 'u <br /> o v v a m m <br /> el Holding Tank <br /> rn L( <br /> sine amber <br /> e r }( <br /> VI 1. Responsibility Statement- 1,the undersigned,jissume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(Print) Plum er's Signature MP/MPRS Number Business Phone Number <br /> rS k0elliti 1Z2 y- 7/d. <br /> Plumbers Address(Street,City,State,Zip Code) r / <br /> ( sAyr Rd b W/ 16 � r <br /> 41-7j <br /> ,Will.. Count /De artment Use only <br /> Approved ❑ Disapproved Permit Pee --DaatYte Issued QQ Issuing en lgnature <br /> ❑ Owner Given Reason for Denial ' 350 - DU <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> %ttach to complete plans for the sysvm and submit to the County only on paper not less than 8 VI x I I inches in size <br />