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eommercomi.gov Safety and Buildings Division [Sa!nitary <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> i s eonsin Madison,WI 53707-7162 Permit Number(to be filled in by Drtment of commerce .5 1 ,95 <br /> In accordance with s.Comm.8321(2),Wis.Adm.Code,submission of this form to the appropriate govemmental tt <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POW TS 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 Priv Law a.15.04 1 m Stats. <br /> I. <br /> Application Information—Please Print All Information _ f /e <br /> Property owner's Name Parcel# <br /> :1?&:F;75 —F0—pertY1=mjon/a3, a ', <br /> PropertyO er's Maling Address ' <br /> ff//// <br /> c ,�Sptate ///G Zip Code Phone Number Govt. <br /> Lot <br /> /!�"le �/ LG5 N/ /'k -2� ,L : L'/', �� '/., Sarson <br /> 7"^-� 7 (circle one) <br /> II.Type of Building(check PPY)all that apply) Lot q T N; R L—.mar W <br /> 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block q <br /> ❑PubliGCommercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> T-- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) Town of -72 <br /> 3:4ZU_Q DOD <br /> _ <br /> A New S tem ❑ <br /> ys Replarxmmt system ❑Treetment(Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Tamfu to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> IV.Type of POWTS S stem/Com onent/Deviee: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized in-Ground ❑At-Grade ❑Mootd>2A in,of suitable soil ❑Mound<24 in.of suitable soil <br /> 9"Holding Tank ❑Oder Dispersal Component(explain) ❑Pretreatment Device(explain) - <br /> V.Dis enalfr a tment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) TSyslcrn Elevation <br /> VI.Tank Info Capacity in Total k o. Manufacturer <br /> Gallons Gallons Uma <br /> New Tanks Existing Tanks a !2 <br /> Septic o ing Tack <br /> Doting Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWT'Sshown on the attached Plans. <br /> Plum u's Name(Pring Plumb ' i re MP/MPRS Number Business Phone Number <br /> � � <br /> Plum 's Address Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Onl <br /> Approved ❑DisapprovedPermit Fee Date Issued Issuing ignatumm <br /> El Owner Given Reason for Denial �J r� U9 <br /> IX.Conditions of Approval/Reasena-(ar.0W*ppreval <br /> Tis pe,,;t IS For 4JLe, a Jf r&t , of a bxUrwmt (&olei �sc;4144r� a =r <br /> Pole G'avw. 1� IS-02t d« diNirwoI Wr Go-v*Rw T d mlwellt:�, <br /> Attach to complete plans for the system and submit to the County vvly on paper vot ten than 8 IR z I I ivchn iv size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />