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CORVnerCe.W1.gOV Safety and Buildings Division County <br /> 201 W.Washington Ave,P.O.Box 7162 Y(A I'H <br /> ti <br /> seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> t,°Pa"nrnn<o.Camrurca 53 2 2 7 L <br /> Sanitary Permit Application State Transaction Number _) <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this fort to the appropriate governmental I <br /> unit <br /> l-- <br /> unit is required prior to obtaining a sanitary permit. NOW: Application forms fm atat wnedl POWTS are Project Address(if different than mailing address) 9u <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes N accordance with the Privacy Law,s.15. l)(m),Slats. I G(S/ C® F <br /> {� <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel N07O•/Y'A A• mS- <br /> • bat � lac <br /> Toa X stn �, 34 oe/-01reo0 018/ Del pp} <br /> Property Owner's Mailing Address Property Location <br /> CA(9 YNekrlen St Govt.Lot _ <br /> City,State Zip Code Phone Number y, y., Section 'AZ <br /> !l LroN SS//3 circle cre <br /> RascUi @ T 40 N; RIfEo45 <br /> IL Type of Building(check all that apply) Lot H <br /> B I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name /n� <br /> Block N V i —102--ol.--cm <br /> ❑PubEdm <br /> Comercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSMNumber ❑Village of <br /> V.;, ID #06 Town of Sc O'f/' <br /> IIL Type of Permit: (Check only one box ort line A. Complete Bne B if applicable) <br /> A. ❑ New System Replacement System ❑Treatmem/H.1ding Tank Replacement Only ❑Other Modification to Existing System <br /> (explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change ofPhmbef ❑PermitTransferto New List Previous Permit Number and Date Issued <br /> Befom Expiration Owner <br /> rIV.Type of POWTS stem/Com onenUDevice: Check all that apply) <br /> IM Nan-Pressm¢ed In-Ground ❑Pr...ized ImGround ❑ At-Grade ❑Mound?2A in.of suitable soil ❑Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explam) ❑Prebeatmant Device(explain) <br /> V.DispersaVrreatment Ara lnformadon: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(al) Dispersal Area Proposed(at) System Elevation <br /> VL Tank htfo Capacity in Total N of Mawfacturer <br /> Gallons Gallons Units �u <br /> New Tanks Existing Tana CCC333 'as' <br /> y y is C7 � <br /> Septic or Hawing Task /d00 /o10 <br /> Domrg <br /> VII.ResponsbiGty Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R.le_k �d /arJI ;> <br /> Plumber's <br /> Plumber's Address(Street,City,State,Zip Code) <br /> x77/.0 bra 3f tvt.Ssfr� ✓r sYP•� <br /> VII Conn /De artment Use Only <br /> Approved ❑Disapproved Permit Fm Date Issued I Issuing Ag lure <br /> ❑Owner Given Reason for Denial S32511 4 AQf <br /> DL Conditions of Approval/Remiss;for Disapproval <br /> Atbah to complete plain for Ilse systes amd submit to the County only os paper not km thus a in 111 basher In size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />