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commerce.wi.gov Safety and Buildings Division Count, <br /> 201 W.Washington Ave.,P.O.Box 7162 (f �ry1Qi f <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 51 7/_0 <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 t�eN'Ev 4016.W V <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(I)m,Stats. //'� uy. 1 <br /> 1. A (_p <br /> Application Information—Please Print All Information 3 12<31 N <br /> Property Owners Name Parcel# <br /> G e n e MAJ <br /> Property Owner's Mailing Address Property Location <br /> ��,1 <br /> �/ I / - Oa6oao <br /> T V✓1 d r d o h4 ll a Govt.Lot <br /> City,State Zip Code Phone Number Section <br /> 5 3S S'2 9 Z o- b Z T VO N_ R ( ctrclE or V� <br /> lMhlne nl�s n s 9 <br /> 11.Type of Building(check all that apply) Lot# <br /> 1$,1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> D Public/Commercial-Describe Use <br /> ❑City of <br /> D State Owned-Describe Use CSM Number D Village of <br /> S L 4-1 1 p '(g Town of E(.G+- <br /> V 3 ,V P s9 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) — _ <br /> A. D New System y 9 Replacement System ❑Trcatmrnt/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. D 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 /> .Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank D Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal(Trestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(-g-pdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> '7 <br /> bo tq:L �fa9 1 97, ' <br /> I VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks v is m72 <br /> r <br /> o a m <br /> MV n t Yn <br /> (L1.1)-Holding Tank <br /> X s i s Fr X <br /> Uosivg 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) Plu tier's Signamr MP/MPRS Number Business Phone Number <br /> AL <br /> S r u� 9 rr Plumber's Address(Street,City,State,Zip Code) -! I/ <br /> 7JCo(,). ,4k- r S((ep <br /> VII County/Delartment Use Only <br /> Approved 11Disapproved Permit Fee /(AJ Date <br /> 'Isssue'd-7� Issum ge Signature <br /> D Owner Given Reason for Denial $�2� -/ '2AWy.rt/� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the s,arem and submit to the County near on paper not las than 8 in z it inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />