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tcommerceml.gov Safety and Buildings Division County <br /> e 201 W.Washington Ave.,P.O.Box 7162 3u Y'M <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit%umber(m be Filled in by Co.) <br /> Deparhrrent of Cornmerce 45 6'9$ <br /> Sanitary Permit Application Stam Transaction Number <br /> In accordance with s.Comm.$3.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Applieatim fomes For state-owned pOWTS are project Address(if different thin mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> a"m accordaone wAh the Priv Law,c.15. I m State. <br /> 1. Applicaden Information—Plea,,print All Wormation , 7379 STeanB <br /> "any Owner's Name <br /> �L Parcel# <br /> S2e7`f l3.k lK Cn. t 30878 oto 4333 o43oo <br /> Property,owner's Mailing Address <br /> Property Conation <br /> 3S b*ti S�. EB Gwl.tat 2 <br /> City,Stam ''// Zip Cade Phone Number Yy_ Yy Section <br /> J— <br /> Save.^ Grove 7'r'rf. MN. S 0 77 G/0(- 91+0- tl4}3 /6(eankmme� <br /> IL Type of Building(check all that apply) Lot# o' T —N; R E a( <br /> 1 or 2 Family Dwelling—Number of Bedrooms � PaIE a c la7 2 LyG FaF tM Subdivision Name <br /> Block# <br /> ❑Public/Commemial—Describe Use <br /> ❑City of <br /> ❑Sisk Owned—Describe Use CSM Numbs ❑Valage of <br /> Vol 1 A 24.2 Town of 04 A1Aa a( <br /> ILL Type of permit: (Check only one box m lune A. Complete line B ir applicable) <br /> A' ❑New System p hcemmt System ❑TredmenbHo <br /> /+BW ri Wing Tank Replacement Only ❑Other Modifration to Existing System(explain) <br /> B. ❑permit Renewal ❑permit Revision ❑ChangeoMmuber ❑PnmitTransfermNme List Previous PervmitNer <br /> umbard Date Lsued <br /> Before Aspiration owner <br /> IV. f POWTS S oCom enNDevice: Check all that a <br /> JoNes-prmur¢ed Inlrrund ❑Prauurized In-Gmuod ❑A4Grade ❑Mwnd>24 is of suitable sore] ❑Mound<yt in.of suitable soil <br /> ❑HoW.g Tank ❑Other Dispersal Compmmm(csplaio) _ ❑PMUcamncat Device(expkiu) <br /> V.Dispersreaftoent Area Wormadon• <br /> Design Flow(gPd) Design Soil Application Rate(gpdet) Dispersal Area Required(at) Dispersal Area Proposed(at) Syemm Elevation <br /> 30In S boo X00 q3, 7p <br /> VL Tank Info Capacity in Total #of Mamkcbrrer <br /> Gallons Gaffom Unita <br /> $ U <br /> New Tanb HwaErg Tendo <br /> _ A m 'tet H i..a E <br /> SipmwHoBug adk d o� Seo B/Ls w <br /> Ibffig Chamber X <br /> VIL Rmpmhsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown an the attached plans <br /> Member'9 Neme(Pant) Renews Sig.umre MP/tAM Number Boniness Phom Number <br /> Ae-le 11" kI" S I /2",4�e� <br /> 8bar-yvs7 <br /> plumber's Address(Sliest,City,state,2rp Cade) <br /> 7 w 3s w .sf,ri t7/� -S�i84? <br /> V[I <br /> OUR /De artment Use Ont <br /> Approved ❑Dicapprved Permits Pee DAaym�Issued Iaeumg goalme <br /> ❑Owner Given Amason forDenial <br /> $ �✓�� /7y/f/C Z�i r(�YJ <br /> IX.Conditions of Approval/Reaaone for Disapproval <br /> Atmel In casspk/e plarmfar W> en and mWt m the Coady only m Apar wal I®Wm 8 ren:1l lothes m xx <br /> SBD-6398(R.01/07)Valid dart 01/09 <br />