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commerce.Wl.gov Safety and Buildings Division Coun y / f <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> iW153sconsin Madison, <br /> 707-7162 Sanitary Permit Number(to befilled inbyCo) <br /> Departmiem of Commerce S32.? 9 <br /> Sanitary Permit Application State ti°nN"°,)b`r <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental t Co Ien j <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Stats. / - 7 y Z z L <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 4/ tI / 55e Z bur ,?o c35-00 <br /> Properly er's Mailing Address Property Location)C- <br /> / yh <br /> .L-)- e-- LJ Govt.Lot <br /> 1�7- <br /> City,State Zip Codpe Phone Number y — y,, Section -2 1 <br /> �n)� �`' O T N; R4one <br /> It.Type of Build' g(check all that apply) Lot# <br /> 9"l-or 2 Family Dwelling-Number of Bedrooms ^ Subdivision Name _ Q1 <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use �� CSM Numbed ❑Village of <br /> -Town of n'4'IL.//'4- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ Treatment/Holdin <br /> ❑ New System lacement System g Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> Jon-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 ersaLTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> Soo Y2 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units d ` <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank /4�06) QQp / 'e-S s-G <br /> Dosing Chamber <br /> VII.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/MPRS Number I Business Phone Number <br /> �61-e t, / � Y9- 7a� 6 <br /> Plumber's Address(Street,City,Slate,Zip Code) <br /> A nor S/5/ 5)% e w G✓ Z g C/� 7� <br /> VIII.County/Department Use Onl <br /> Approved ❑ Disapproved Perm2it Fee Date Issued-- Issuin Signature <br /> El Owner Given Reason for Denial $ ✓ J:R' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the Can my only on paper not less than a tl3 x I l inches In size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />