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tcoffirnerceml.gov Safety and Buildings Division County <br /> ill SC011 S a 201 W.Washington Ave.,P.O.Box 7162 r3u r ti C - <br /> Madison,Wl 53707-7162 <br /> e(aarhnent of Commerce Sanitary Permit Number(m be Filled in by Co.) <br /> Sanitary Permit Application SlaeTmneaction Nur <br /> In accordance with e.Conor.83.21(2),Ww,Adm.Code,submission of this form m the appropriate governmewl <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for stateowned POWTS are <br /> submitted too the Department of Commerce. Personal information you provide may be used for secondary <br /> Project Address(if different than mailing address) <br /> pur,oscs in ccerdance wrth the Privam),Stab. <br /> I. AHentsffum Information-Please Print AB T,f Mation CM979 Ora rre <br /> Property Owner's Name <br /> S <br /> Parcel# <br /> L G )>ltve g, , 22 od8- 14109 10 62 <br /> Property Owner's MailingAddress <br /> 3 N 9Property Location <br /> 1sD;ti sf. <br /> City,Sb4 Zip Code phone Number Govt Lot <br /> L p Z kW ✓may$5'3 —v,—v, section 9 IryL/ Type of Building(check an that aPP1Y) Lot# T NO N; R !q(tack:on E o� <br /> p 1 or 2 Family Dwelling_Number ofBedmoma d� Subdivision Name <br /> ❑PublirJCommercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> I�Town of SC e ?174I II.Type of Permit (Check only one boz on Ihse A. Complete line B N appBcable) _ <br /> A ❑New System [� Sf Q <br /> Replaceurrnt System ❑TreatnrrnnHokling Tank Replacement Only ❑Other Modification to ExistingSystem Y stmt <br /> (explain) <br /> B. ❑permit Renewal ❑permit Revision ❑ previous Permit Number and Date Issued <br /> Before Expiration Change of Plumber ❑PermitTranafa to New LiatP <br /> Owner <br /> IV.T e of POWTS stem/Com wre ryDeviee; juneck all that apply) <br /> IN Non-Pressurized 1--r oand ❑pressurized ht-Ground ❑Al-Gmde ❑Mound>24 in.of suitable soil ❑Mound<24 w of quibble soil <br /> ❑Holding Tank ❑Otha Dispessal Component(explain) <br /> V.Di ersal/I'reatment Area Information: ❑pretreatment Device(explain) <br /> DesignFlow(gpd) Design Soil Application a Rate(gpdat) D <br /> '300 proal Ares Required(&DDopemea al A proposed(at) System Elevation <br /> VI.Tank Wo600 �O0 <br /> C'Pa°itY in Total #of Manufacturer • <br /> Gaflom Gallons Units <br /> New Tanks Bxieting Tanks <br /> a <br /> SepacwHokling Tads8 <br /> � <br /> Danngadg Clamber -SlLst /✓ <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation orthe POWTS shown on the attached plana. <br /> plumber's Name(Pratt) Plumber's Sigmtme <br /> MP/MPR$Number Buein <br /> 2lG IG d IG/Hms Phone NumberS <br /> Plumber's Address(Street,City,State, 'y/S- e(r 6 E 11S• <br /> 770 1�w 3s Gr/�bs)!rr (yam S�laS3 <br /> VIIL Coon /De sounent Use Ohl <br /> ❑Approved ❑Disapproved Permit Fee '--� Date Issued IUU <br /> S <br /> g tgmture <br /> ❑Owner Given Reason for Denial <br /> UL Conditions of ApprovsUReasans for Disapproval <br /> AHarh m eo�plete phmfartlw rystaw sed as6W1 b the Cm <br /> dY m1Y m papa'rot ks then a 12:ll lochs ti alae <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />