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cemmerce.wi.90V Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 V1 r <br /> isconsin Madison,WI 53707-7162 Sunny Permit Number(to befilled inbyCo.) l �11 <br /> Depaeimem of Commerce SZ/ Y <br /> Sanitary Permit Application Stare T ansact on Number w <br /> FacwrdZan"With s.Comm.8321(2),Wis.Adm.Code,submission of this form to thea m ed PP Priamgoverame be prior m obtaining a saukary permit Nom: Application forms forstateowned POWTS are Project Addre�(ifdiReren[than mailing address)the Depethnent of Commerce. personal information you provide may be used for secondary <br /> in accordance with the Law s.i Ali 1 m Stats. <br /> L A rtn <br /> Application Infoatioa-—Please Print All Information <br /> Property Owner's Name <br /> C Pamel# <br /> Property er'SMailing Address <br /> 0.z <br /> Property Location <br /> City,Stam Zi Code Govt Lot <br /> P Phone Number <br /> I s r I`p Al . 5�'/., Section <br /> p�/ -1 0 I 7� - � 1 3 71 (circle one], <br /> It.Type of Building(check all that apply) Lot# T.. N: R,1�__E o /\ <br /> ®1 or 2 Family Dtveliing-Number of Bedrooms_� Subdivision Name <br /> Block# <br /> L]PublidCommemial-Describe Use <br /> ❑City of <br /> ❑State Osmcd-Describe Use CSM Number ❑Village of p <br /> IX To—of_Rfl/"i�ir' rb ' t <br /> in.Type of Permit: (Check only one box online A. Complete fine B if applicable) <br /> A. <br /> ❑New System QXReplacement System ❑T—tm-NHoldiag Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> H- ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pemtit Transfer m New List Previous Permit Number and Dam Issued <br /> Before Expiration Omer <br /> IV.Type ofPOWTSS tem/Conaonent(Device: Check all that a 1 <br /> ❑Non-Pressurized In-Ground Pressurizedfin-Ground ❑AFGmde ❑Mound>24 in.ofsuitable soil ❑Mound<24 in ofsuimble soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Preveahnent Device(explam) <br /> V. <br /> isens reatment Area Information: <br /> Design Flmv(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(e) Dispersal Area Promised �1(0) Sy mm Elevation <br /> 4 5 9G� 9z3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tavks -� U = <br /> Septicor Holding Tank i3OOO i <br /> Dosing Chvmher (PVO <br /> cam b.r �c <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for iustelaGon of the POWTS shoran on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> w ' F _ <br /> Plumber's Address(Street,City,State,Zip Code) 9 SF <br /> PUCauduibum. <br /> Con a ar[tn t Use Unly <br /> ❑Disapproved Pean2itFce Dale Issued - IssuiagA e <br /> ❑Owner Given Reason Cor Denial si/��ofApprovaUReasons for Disapproval <br /> Attach m mmplele plans far tae system and sobmil to the County only on paper no[las than B rn r t I inches in size <br /> SBD-6398(R.01/07)Valid than 01/09 <br />