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commerceml.gov Safety and Buildings Division County /1 <br /> sc o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be <br /> 201 W.Washington Ave.,P.O.Box 7162 lain eT1- <br /> i filled in by Co.) <br /> Department of Commerce 54C)4-3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Cade,submission of this form m the appropriate governmenta <br /> Note: Application <br /> m <br /> unit is required prior obtaining a sanitary permit. forma for state-owned POWTS are Project Address(ifdifferent than mailing address) ^ <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> pun2sca in accordance with the Privacy Law,a.15.04(1)(m),Stats. / <br /> L Application Information-Please Print All Information - x.7.3'86 Rs;-<z RA <br /> Property Owner's Name Parcel q <br /> o�d-wOvb-33-S Q� <br /> Property Owner's NbFilin✓g'1A------ <br /> 0avt L a 15- 01L5o'ca-tioon <br /> d 9000 <br /> 670tI property <br /> / <br /> h Qt W 4 Govt.Lot <br /> City,state yrs Zip Code Phone Number <br /> CtNttr v)lIC //!N SSD3S Section 33 <br /> IL Type of Building(check an that apply) �S� 8 3 9b 9 I T NO N; R /b(cvc1E ore® <br /> 1 or 2 Emily Dwelling-Number of Bedrooms 3 7¢ g' Subdivision Name <br /> Black" Albut I c.4 � ea R�Jt tzg <br /> ❑PubbdCommercial-Describe Use <br /> D Cityof <br /> D State Owned-Describe Use CSM Number D village of <br /> JR Town of OA 141A A <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B V applicable) a _ -7 <br /> A. — <br /> p� - <br /> D New System pi Replacement System D Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑permit Revision ❑ Chan a of List Previous Permit Number and Date Issued <br /> 8 D Permit Transfer to New <br /> Before Expiration Owner <br /> N.T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> PrNon-Pressurized In-Ground D Pressurized 1n-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) O Pretreatment Device(explain) <br /> V.Dis ersallTmatment Area Information: <br /> "cargo Plow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(af) Dispersal Area Proposed(sf) System Elevation <br /> YJ G 43 G 5l 8 <br /> VI.Tank Info Capacity in Tofal q of Manufacturer <br /> Gallons Gallons Unita ApIms.New Tank. Bxisting Tanks cam^. `ho n at� s r7 0.Dosiing Chamber /ms ,9 a✓ XVII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attachedPlumber's Name(Print) Plumber's Signature MP/MFRS Number ber�,�,SSrS/ /S7 <br /> Plumber's Addreae( treat,City,Sete,Zip Code) <br /> 1 760 /) hw 5weIb.s7l, w7 Srf893 <br /> VIIL Coun /De artment Use Only <br /> Approved DDisapproved Permit Ep�ee Date Issued Isauin ISignature <br /> ❑Owner Given Reason for Denial B-Jo(S� 13A alL �(' <br /> M.Conditions of ApprovaVR .sx for Disapproval <br /> Atfach to romple4 pure forth systeu and aubma b the County ady an paper rW kis than S 1rs a ll imha in aiae <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />