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oommeree.wi.gov Safety and Buildings Division Coun <br /> 201 W.Washington Ave.,P.O.Box 7162 0 <br /> isconsin Madison,W153707-7162 Sanitary PermitNumber(to beMRinb-Co) <br /> Department of Commerce e�J 2>^ <br /> Sanitary Permit Application State action Numn r�r\ <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental eW �/ I <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 c> <br /> u sea in accordance with the PrivacyLaw s.15.04 1 m Stats. <br /> I. A Iication Information-Please Print All Information r <br /> Property Owner's Name <br /> Parcel 11 7 aao a i o <br /> &0 r'c-,a c- of 3 0 <br /> Property Owner's Mailing Address s Property Locatio0 O <br /> U <br /> la - Govt.Lot <br /> City,State Zip Code Phone Number �� ff <br /> ��''/.,�W'/., Section-� <br /> ILT eotBuildin SSO 2 T vq N; Rl (circleone <br /> YP g(check all that apply) ��J/ Lot A __[_CL —E Q& <br /> %Lor2 Family Dwelling-Number of Bedrooms C;C Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use �— _ <br /> ❑City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use L <br /> XTown of_Q /� <br /> III.Type of Permit: (Check only one box oaline Complete line B it applicable) _A. -im_❑New System Replacement SysTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision Change of Plumber ❑Petmit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner1V.T e of POWTS S stem/Com onent/Dheck all that apply) <br /> won-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound a 24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersavrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(sQ Dispersal Area Proposed(sT System Elevation <br /> 300 0 �a so yso <br /> VI.Tank Info Capacity in Total p of Manufacturer <br /> Gallons Gallons Units <br /> O 9 _ <br /> New Tanks Exiatug Tanks <br /> a V in N y k+. C7 ii <br /> septic or HoWiaaTank 76-6 <br /> Doaing Chemher <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim Plumber's Signature MP/MPRS Number Business Phone Number <br /> de a /7, G,J 4 zz769/ 3y9-7.zg6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL Coun /De artment Use Only <br /> ogf <br /> Approved ❑Diaapproved Permit Fee Date Issued Issuing ent nature <br /> ❑Owner Given Reason(or Denial a <br /> IX.Conditions of Approval/Reasons for Disapproval 2CilVE nt, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 x It ini ze1C r _ <br /> 11..I 90+l <br /> SBD-6398(R.02/09)Valid thm 02/11 BUR IOONI,aV NTY <br />