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commerceml.gov Safety and Buildings Division may <br /> a 201 W.Washington Ave.,P.O.Box 7162 4t <br /> i seo n s i n Madison.WI 53707-7162 Sanitary Permit Numb"(to be filled in by Co.) <br /> Departmarrt of co innmarce (0 3 7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental J 38 0 $V <br /> unit is required prior to obtaining a sanitary permit. Note: Application fonts for erato-owned POWTS are Project Addms(ifdifferent than marling address) <br /> submitted to the Department of Commerce. Personal information you provide may be mod for aecondary <br /> ImrP0sea in accordance with the Priv Law,s.15. 1 )'Stan. k f � ,,[7 <br /> I. A ticatimn Information-Pleax Print All Intiarmation JdG NJ lH Zle_I?rf' () ) <br /> Property Dwner'a Name Parcel# fit/ <br /> /zeif(,Y `a- SalwWvt /3rew rn �, a 6,10 -4J,t3— dll,e0 <br /> Property Owner's 9&lhag Address <br /> Property Location <br /> s7s ,e�- Amts. <br /> City,Slate Govt Lot_7_ <br /> Zip Code Phone Number 3 <br /> yS '/., section <br /> S• 1.5 /f'1 A/ � .$—H fg.3 (cwcle one <br /> rrI�aL� Type of Bmtklmg(check all Unit apply) T Lot# T N; R /G E o& <br /> su l or 2 Family Dwelling-Number of Bedroom Subdivision Name <br /> Block# <br /> ❑Public/Commemial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe UseCSM Nundrer I❑7 Village of <br /> y� To"of 0,4 k 14 07 <br /> Ill.Type of Permit: (Check only one box ran lime A. Complete Site B if applicable) <br /> A. ❑ New System Y Replacement Sys[em ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing Syetan(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑PermitTramferto New Lunpre"m"Permit Number and Dam lasued <br /> Before Expiration Owns <br /> TV.T of POWTS stem/Com onent/Device: Check all dust apply) <br /> ❑Noa-Pressurized In-Ground ❑pressurized In-Ground D A1-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holdmg Tank ❑Otha Disposal Component(explain) ❑Pretreatment Device(explain) <br /> V. rsalfrreatntent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> H.S'O <br /> VL Tank Into Capacity in Total #of Mamdacturcr <br /> Gallons Gallons Unita <br /> New Tsih Exuam;Tanks V a <br /> Septic or Holding Tank GGCC V :n rn }s,�7 a <br /> /3s3a <br /> her X <br /> Davrg CFsrn <br /> VII.ResponsibBity Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Punnocr a Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /<f c G /� /c t . /�a.,o.ba.� S€b'-) 7{f <br /> Plumba'4 Adams(bucet,city,State,Zip Code) <br /> 776 w -R-4— <br /> = <br /> -4— GtJ26J��� l.�1 S4S'97 <br /> VIIL Corm /De armrmt Use Only <br /> Appmved ❑Disapproved Parch Fee Data Issued Issuing ent tune <br /> $❑Owns Given Reason for Denial <br /> IX.Conditions of Apprival/Reasom for Disapproval <br /> Anseh to remplele plans for the systrot and submit to the County only an taper ant kw than 8In all hand Inalae <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />