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cOmmeree.wi.gov Safety and Buildings Division Cou� <br /> 201 W. Washington Ave.,.P.O. Box 7162 '✓ Q { r' <br /> yf i seo n s i n Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Departmem of Commerce 5;Z 10 62Z <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2).Wis.Adm. Code,submission of this form to the appropriate governmental _aI <br /> unit is required prior to obtaining a sanitary permit. Note'. Application forms for state-owned POWTS 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 wide the Privacy Law,s. 15.04(1 am),Stats. / <br /> I. Application Information-Please Print All Information <br /> Propem Owners Name Parcel# <br /> use O -WY- c (foo w <br /> ropem O%tners Mailing Ad rens Propem Location <br /> 7 ,e Q �, Govt.Lot 0 <br /> y, <br /> Cin.State Zip Code Phone Number �= X16y,, Section C>Q <br /> r �/ / circle one ( ^, <br /> 1 Y' 7 (a 1- �+w- T�N, R�Eor <br /> H.Type of Building check all that apply) Lot# <br /> Subdivision Name <br /> I or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑ Public/Commercial-Describe Use ❑ City of <br /> i <br /> CSM Number ❑ Village of <br /> 11State Owned-Describe Use , . / ��,/ <br /> Town of(,(J {ry tQts44K <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' p New System Replacement System Treatmem/Holding Tank Replacement Only Other Modificaon to Existing System(explain) <br /> B. El Permit Renewal ❑ Permit Revision ❑ Change to New of Plumber ❑Permit Transfer List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com onent/Device: (Check all that app I <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound 1 24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arca Required(sf7 Dispersal Area Proposed(sf) System F,levation <br /> 3 00 , 6 5Z10 s60 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> A vce <br /> New Tanks <br /> Existing Tanks u o v y m m <br /> epnc Holding Tank 700 1 //� Y <br /> I)o,na Chamber IN /` <br /> V 11. Responsibility Statement- 1,the undersigned assume responsibility for installation of the POW TS shown on the attached plans. <br /> Plumbers Name(Print) Plu bees Signature MP/MPRS Number Business Phone Number <br /> Oev r 22S2Z ]ice ���� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> V111.Count /De artment Use Only <br /> Permd Fee Uale Issued lissumig/Agrent insure� <br /> Approved ❑ Disapproved seg <br /> ❑ Owner Given Reason for Denial $ ���i 23 f ne rV <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> l <br /> I <br /> i <br /> Ntach to complete plans for the system and submit to the Counry only on paper not less than 8 In x I I inches in sae <br />