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COITlmerce.wi.gov Safety and Buildings Division Cour)ty ` <br /> 201 W.Washington Ave.,P.O.Box 7162 it PA se „rL <br /> i s co n s i n Madison WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Dopartmem of Commerce r a'l <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.8321(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stateawned 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. �O � ��� 'I YQ <br /> I. Application Information-PleasePrintAllInformation <br /> Property Owner's Name n parcel# <br /> Gu S �uFSe—� 3 O 07-03y-�.-37-15 -L o3-ooZ)- <br /> Property O er's ailing Address Property Location 01z 000 <br /> Govt.Lot <br /> ity,State Zip Code Phone Number , 2S <br /> r f� S(� '/.,ill W /a, Section <br /> pP \err < S� 3 / ?j,/ -R S cucleone <br /> i 7 tr T N; R�Eone <br /> ddIT.Type of Building(check all that apply) � Lot H - <br /> tp 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> El State Owned-Describe Use <br /> CSMNumber ❑Village of <br /> �Town Of-6; t <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer ro 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 /> t(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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> q50 . l 43 1 & v 9 . o <br /> VI.Tank Info Capacity in Total p of Manufacturer <br /> Gallons Gallons Units o v o <br /> New Tanks Existing Tanks gwv <br /> _ 4 U in eo w U <br /> c ticy Holding Talc OOv <br /> Dosing Cbamber I` <br /> VII.Responsibility Statement- I,the undersigns ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu tier's Signamr MP/MPRS Number Business Phone Number <br /> �(S aeY r 2ZSz2 7f (o-$ <br /> Plumber's Address(Street,City,Stale,Zip Code) <br /> 7 85'�_ � <br /> VI 1.Count /De artment Use Only <br /> ❑Approved <br /> El Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> a <br /> El Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 inches in at. . <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />