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commerce.wl.gov Safety and Buildings Division Court <br /> U <br /> 201 W.Washington Ave.,P.O.Box 7162 e <br /> iseonsin Madison,W153707-7162 Sanitary Permit Number(to be filled in by Co,) <br /> Department of commerce C:i <br /> Sanitary Permit Application Stater aacit nNamber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental writ Lit Lit eGve/t, <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stale-owned POWTS are ProjectAddress(ifdit£erent 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,s.15.04 I m,Stats. 377/ G <br /> I. A lnfo <br /> licationrmation-PleasePrintAllInformation / b <br /> Property Owner's Name r Parcel# p u <br /> r ur AI C d <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lo[ t7 <br /> City,Stale Zip Code Phone Number <br /> SJ�a 7s '/•, Y., Section <br /> cycle one <br /> II.T eo[Building i �N; R Eo <br /> yp g(check all that apply) Lot# <br /> �M_m­2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of �t— <br /> `TVownof 4c-h5a/y <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ _ _ _711sswd <br /> 7 <br /> A. New S stemy ❑Replacement System ❑Trea[mentMulding Tank Replacement Only ❑Other Modi(ca[ion[o Ex❑Chane of Plumber List Previous Permit Numbe <br /> B. Permit Renewal Permit Revision g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onenVDevice: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 4 `�— <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons <br /> New Tanks Existing Tanks $ y g <br /> 0 <br /> J. V <br /> SW+eer Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> lumber's Address(Street,City,State,Zip Code) <br /> VIII. <br /> Co ' <br /> t /De artment Use Only <br /> Approved D Disapproved Permit Fee Date Issued Issuing A gmdure <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Nk> St,rEaU aria,. pr in 0„-S/{- S611 ALsw016161a. GeA is r 9f:t 6K 'ELf z4f. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 9 la x l I Inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />