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commerce.wl.gov Safety and Buildings Division County <br /> a201 W.Washington Ave.,P.O.Box 7162 a✓n e f 4 <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of commerce 540,33c) <br /> Sanitary Permit Application State Tn on Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental tJ l <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for stateowned POWTS are Project Address(ifd���thaa mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary �� <br /> purposes in accordance with the Privacy Law,a.15.04(1 m),Stats. ,AA /�r��/G <br /> I. A Bastion Information-Please Print All Information ,i f RP <br /> Property Owner's Name Parcel N(l/, o7-pl1'Z' 15',3 -p( <br /> peimwt ®l� etA3h®b 7o0 <br /> Property Owner's Mailing Address Property Location <br /> 3 7 0,1 74.h fa Gr <br /> City,State Zip CodeGovt.Lot <br /> Phone Number 7 <br /> Ys Ye, Section ,7 6 <br /> cacle onc)a, <br /> �ILr Type of Building(check all that apply) Q Lot a <br /> T �{� N; REa / <br /> n,[1 or 2 Family Dwelling-Number of Bedrooms o` Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> a Town of Jai-�'f�� <br /> Ill.Type of Permit: (Check only one box on IhreA. Complete line B if applicable) <br /> New System ❑Replacement System ❑Treatment/Holdmg Tank Replacement Only ❑ Other Modificatim to Existing System(explain) <br /> B. ❑PermitRaewal ❑Permit Revision ❑ eofPlumber List Previous Permit Number and Date Issued <br /> Chang ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onentlDev)ce: Check sill that apply) <br /> Non-Pusauriud In-Ground ❑Preeaurimd In-Ground ❑ At-Gude ❑Mound>24 inof suitable soil ❑Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Compommt(explain) ❑Pretreatment Device(explain) <br /> V.Di s ersanteatm t Ara hrformation: <br /> Desi�r Plow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required a Die <br /> Sop (f) penal Auer Proposed(et) System Elevation <br /> 47$ Inrj <br /> VL Tank Info Capacity in Total k of Manufaclmer <br /> Gallons Gallons Units <br /> O V <br /> New Tants lixistkg Tmks <br /> 3 m <br /> y m y W t7 i1 <br /> Septic or Holding Tank ;r-e 0 O <br /> Dosing Chamber <br /> VII:Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> /z,r=lect- 1r/ 1el-_5 /2-4.1� 0(,157rsi lis— 8Ge- S'/s 7 <br /> Plumber's Address Street,City,State,Zip Code) <br /> 7 X60 3 tf/e&r�r, avS �'YSei <br /> VI Court /De arlment Use Oul <br /> Approved ❑Disapproved Permitrcc ,.r� Date Issued Issum Siguatuu <br /> ❑ Owner Given Reason for Denial S ,5,?5 ..,(� r) <br /> IX.Conditions of Apprraywmca rsu,fm,Disapproval <br /> Attach to complete plans for the system and mbmit m the County andy ons paper not lea tlm S Irs x 11 inches m airs <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />