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commerce.wi.gov Safety and Buildings Division County '7 <br /> 201 W.Washington Ave.,P.O.Box 7162 /3N rn e7>L <br /> tIsaIsartment scons i n Madiwo.WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> of Commerce S3 21 SO <br /> Sanitary Permit Application Suite nTTrransaacction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (.Join y ft w1 L40 <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(ifdifferen[than 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. 1)m,Stats. a, $75'0 �rGu+SPrTnf �' <br /> L Application Information-Please Print AD Information <br /> Property Owner's Name Parcel M <br /> / <br /> IM G'raca 3 O/a- 9750 - of d0o <br /> Property Owner's Mailing Address Property Location <br /> /Swe <br /> Or-cllat rp 0.-. Govt Lot <br /> City,State Zip Code Phone Number yy Y., Section /.T <br /> /act rn3 v r�/C IH N. SS30 b (circle one <br /> IL Type of Building(check all that apply) Lot# T 40 N; R /.'l- E o� <br /> I or 2 Family Dwelling-Number of Bedrooms 0 S Subdivision Name / <br /> Block# %pour SM4, "rho, -to tvl <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of jAe.,Faro n <br /> 11L Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> p'' ❑New S stem �ryR lacement S stem ❑Y p1 eP Y <br /> Treatment/Holding TankItcplaccoarent Only ❑Other Modification to Existing System <br /> (captain) <br /> B. ❑Permit Renewal ❑Permit Revision <br /> ❑ Change of Plumber 1 ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> rIV.T of POWTS stem/Com onent/Devioe: Check all that apply) <br /> y <br /> ra Nen-Pressurized In-Ground ❑Pressurized br-Ground ❑At-Grade ❑Mound>24 inof suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispenallTmatnesit Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdaf) Dispersal Area Required(et) Dispersal Area Proposed(sf) System Elevation <br /> 31 0 S Geo Goo W• o <br /> VI.Tank Wo Capacity in Total k of Manufacturer <br /> Gallons Galloon Units y o$ w <br /> New Tanks fisting Tants <br /> Septic or Holding Tads 8��' 80Q / S/Lr ✓ x <br /> Dating Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> R1 GIG 1710P/["n S �uw�c /� d•%s'�s`/ 7iS- $66- 4.6-y <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> at776a t-'Kwy 3s We6s2'ei WS S`tSSJ <br /> VIIL Comity/Department Use Only <br /> Approved ❑Disapproved Permit Fee.( Date Issued Q Issuing Pat- <br /> 0 Owner Given Recon for Denial $3.2✓ � iC 0 f'{u O 7 <br /> IX.Conditions of Approval/Reamons for Disapproval <br /> Minch to compete plus for the system and submit tothe Courcy only an paper not lea than 8 to z 11 lochs In size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />