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eommeree.wi.gov Safety and Buildings Division County <br /> 201 WWashington Ave.,P.O.Box 7162 etc,r h-e`f <br /> W. PennitNumbeet11(to be filled in by Co.) <br /> ' (i s eo n s i n Madison,WI 53707-7162 Sanitary <br /> Department of Commerce S z 1 - <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental / 1 t <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POINTS are Project Address(if different than mailing address) w <br /> submitted to the Deparhnent of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,S.15.04 1 m,Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# A 8._r-0 3 �oo a <br /> J <br /> J .. - G�- °40-3-34' !9' _nu/oo <br /> oS�t ! � ><c✓5 <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number 3w 7. Nb Yy Section <br /> 5 y S 93 (circle one) <br /> GNAy t5� t r (IJ/ T 39 N; R /9 Ent <br /> II.Type of Building(check all that apply) Lot# <br /> J9 I or 2 Family Dwelling-Number of Bedrooms X51 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSMNumber 3ff07 ❑Village of <br /> El State Owned-Describe Use <br /> W zz , S Town of WeSf jnav5h/�rh� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ _ _ - - -In-nil I op <br /> A. <br /> - <br /> A' LYNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Otho Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B <br /> ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that a I <br /> IYNon-Pressurized In-Ground ❑Pressurind 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.Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sT) Dispersal Area Proposed(st) System Elevation <br /> 3aU 5` Coo G00 qs. O <br /> VI.Tank Info Capacity in Total #of Manufacturer gg <br /> Gallons Gallons Units E tj 3 <br /> New Tanks Existing Tanks <br /> U in H rn w C7 a <br /> Septic or Holding Tank 5rt' o gee / s/Gp w <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /7/�I� ffe ern s /2 � tiles f� a(1Sef <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Count 00/De artment Use O <br /> Permit Fee Date Issued Issuing Age i re <br /> Approved ❑DisapprovedIA ,r.(, <br /> ❑Owner Given Reason for Denial S 3z5 f VA tl/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Aaach to complete plans for the system and submit to the County only on paper not leas than g lax 11 inches in Sim <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />