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eommerce.Wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 $u r n -,e <br /> i s eo n s i n Madison.WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 185 1 1 / 1 (fl f l <br /> Sanitary Permit Application Sta✓ta TT nsactiolnONumber ` `ll R' <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental VfIG eV� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(ifdifferent than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary , <br /> ExuEses in accordance with the Privacy Law,s.15.04(1)(m),Stats. !y p/_ w <br /> I. Application Inform/a,'ti'on—Please Print AN Information Y/ vt <br /> Property Owner's Name r-t t.�ber Parcel ap7-0a $.g-ty0-/4-ir <br /> ?A; / 9�el�s.f;��JS 0S' &V3 . o/3 oso <br /> Property Owner's Mailing Address Property Location <br /> �63� �nla <br /> Loh—o' ri rK , <br /> Goer.Lot <br /> City,State 7:..r„drI I Phone Number 6ma1.Grt <br /> �L Y., Y., Section 6 <br /> (nn �S MN ✓J�I0ybcle(circle one) <br /> TtIpLL Type of Builking(ch k all that 4O N; R /that apply) Lot k <br /> y I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block H <br /> D Publie/Commercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSMNumber 38/697 [1 Village of <br /> I/ .,A I P log J9 Town of .fC& <br /> Il L Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A. New System y 11 Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. D Permit Renewal D Permit Revision D Change ofPlumber D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner _a <br /> pIIV��.Type of POWTS S stem/Com onent/Device: Check all that apply) a <br /> JRfNon-Pressurized In-Gmund D Pressurized In-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Di ersayrreahncat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required(st) Dispersal Area Proposed(sl) System Elevation <br /> 600 , 7 5�.r7 814.y 44.0 93, ! <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> V <br /> Gagons Gallons Uniu <br /> New Tmd;.s Fxistmg Tanks <br /> Septic or Holding Tam /} O 0 /�B <br /> Dosing Chamber '75'70 '7f0 <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/Iv1PRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,V IL Corm /De artment Use Only <br /> Yl Approved D Disapproved Perms Fee Datelssued lssuin Skigna <br /> a 1✓� <br /> D Owner Given Reason for Denial fi0 4 411 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Rel1fGWr4 of &-Ptru fe mk -* <br /> Attach to compete pans for the system and submit tothe County only an paper net kir than 81R Ill Inches in sire <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />