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orrtmeree.wi.gov Safety and Buildings Division County ,R <br /> 201 W. Washington Ave., P.O. Box 7162 54 r h e <br /> eo n s i n Madison, WI 53707-7162 Sanitary Permit Number(to be <br /> tLirtirthearil filled in by Co) <br /> of Commerce 2 J06, <br /> Sanitary Permit Application Slate Transaction Number <br /> In accordance with s. Comm.83.21(2).W is.Adm.Code,submission of this form to the appropriate governmental _V.— <br /> unit <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 /> suhmated to the Department of Commerce. Personal information you provide may be used for secondary _ <br /> purposes in accordance vitt the PrivacyLaw,s. 15.04(1 xm),Stals. ��' <br /> 1. Application Information—Please Print All Information t <br /> PropemOwners Name <br /> Parcel a <br /> 017-06-•a_39-1Ga -0l6 3-03-o0C <br /> Pmpem Go'ner's Mailing Addr ss'/ , / Property Location ZJ[[ G UD <br /> I d— �� 1 Y'T(.e d`E' 4 a Govt. Lot , - , <br /> Cite.State Zip <br /> Code /! Phone Number y, ��+ y, Section <br /> . �7 <br /> �rkyy. �(,rY 1 r �J `Y(�Y'� 7r7 D gC15,0 <br /> le <br /> T�N; REyrIf W <br /> If <br /> Il.Type of Building( eek all that apply) 1 Lot aKa. W <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block a <br /> ❑PubhcdCommercial-Describe Use <br /> ❑ Ciry of--- <br /> 0 <br /> f__❑State Owned-Describe Use CSM Number ❑ Village of <br /> Vi Town of (art7/1 OYL <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> .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 to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IN.Type of POWTS System/Component/Device: (Check all that apply) <br /> KNon-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 /> Desi n Flaw(gpd) Design Soil Application Rale(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed is Sysfcm flcvation <br /> CO �/Z 4�5� 2Z , 006 <br /> Vl.Tank Info Capacity in 'focal q of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks U <br /> v H n <br /> L o V a <br /> L u rn in a U i1 <br /> Sept or Holding Tank <br /> nme Chamber �✓ K/ <br /> V 11. Responsibility Statement- I,the undersigned, 'some responsibility for installation of the POWTS shown on the attached plans <br /> Pluis Name(Pr ) Plumb is Signature MP/MPRS Number Business Phone Number <br /> 1 <br /> e[S /(cOer r 7-2Toazy <br /> Plumbers.Address(Street,City,State,Zip Code) <br /> VIII. Ccounty/De artment Use Only <br /> Approved 11Disapproved Perm <br /> �(it�Pe/e� Date Issued pp Issuing a ignature <br /> ❑ <br /> Owner Given Reason for Denial $ s � A s�U <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ,attach to complete plans far the system and submit to the County only on paper not less than 8 In z 1 I inches in sue <br />