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COQlhflerCemi.gOv Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 (3t k e H to t'f <br /> isoon s i n Madison,WI 53707-7162 SanitaryP it Number be£riled in by Co.) <br /> Depar[rllerrt of Commerce <br /> Sanitary Permit Application Slate Tramad'on Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental --r> - (� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forme for state-owned POWTS me Project Addr s(if different than mailing address) <br /> submitted N the Department of Commerce. Personal information you provide may be used for secondary <br /> puriames in accordance with the Privacy Law,e.15. 1 m),State. <br /> I. Ali Rp <br /> A isan tiInformation-Please Print for <br /> Inmation <br /> Property Owner's Name Parcel# <br /> Teavr 1n,t1Ao11xm 013 O - 9('Ab o(9/0 <br /> Property Owner's Mailing Address property Locat ion <br /> /J• e. r ed R.I. N Gm4.Lot <br /> City,State zip Code Phone Number ye, '/y Section <br /> I?o6erfs S-4,0643 (circle one) <br /> IL Type of Building(check all that apply) Lot# T�� i R (¢ E o� <br /> 1 or 2 Family Dwelling-Number of Bedrooms A � Subdivision N me <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Vq] s BTown of fCi1� <br /> IIL Type of Permit: (Check only one box m Ihte A. Complete line B if app'cable) <br /> A. ❑New System Replacement System ❑Treat t/Holding Tank�Placement Only Other Mod fication to psistig system(explain) <br /> B. ❑Permit Renewal ❑Permit Revuiou <br /> ❑C'hangeofPlumber ❑Permit Transferto New Lot Previous I mart Number and Date Issued <br /> Before Expiration Owner <br /> 1V.Typeof POWTS stem/Com ret/)etice: Check all that apply) <br /> ®Nan-Pressurized In-Ground ❑Preeeumned hr-Ground ❑At-Gnh ❑Mound>24 in.of suitable soil ❑ Mound< in.of suitable soil <br /> ❑Holding Tads ❑ONer DispersalComponent(caplam) ❑Prcaoatmmt Dcvicc(uplain) <br /> V.Dispersalffresitment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdet) Dispersal Area Required(at) Dispersal Area Proposed(sf) Systern Elevah <br /> X00 S` 600 600 9�• ( 9'i'� <br /> VL Tank Wo Capacity in Told #of Mamrfacmrer <br /> GaRom Gallons Units <br /> New Tanks EtistingTmks gSg y ° $ g <br /> Septic or Holding Tank 7-4-0 75,0 <br /> D .'v Cl1B1°b" m0 Ts0f9!19rz 1462 <br /> VIL HesponsibiBty Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the afted plans <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Bwmcas Pho se Number <br /> leial-- /r/0"o/eI".s� // o�ots�ri �s Frr,s- 4is y <br /> Plumber's Address(Street,City,State,zip Code) <br /> 77dd w 3s— Gvebft� � wrs-Y�� <br /> VI L Cosm /De artmast Use Only <br /> Approved 1 ❑DisapprovedPermit FF- Date Issued Iaaumg Signature <br /> 11 Owner Given Reasonfm Denial S ' 6 <br /> IX.Conditions of Appreval/Reasons fon Disapprove] <br /> Arach to eamplde plans car the system and submit to the Csnsay only an paper oat lea dam a M all Inches inloe <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />