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commercemi.gov Safety and Buildings Division Coun r/ <br /> 201 W.Washington Ave.,P.O.Box 7162 k f h e f <br /> yf i s e o n s i n Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 551 Z e5 <br /> Sanitary Permit Application SuiteT act on Number <br /> In accordance with s.Comm.83:21(2),Wis.Adm-Code.submission of this form to the appropriate governmental C/Cu7 <br /> unit is required prior to obtaining a sanitary permit. Nota Application fortes 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 <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Stats. /07-77 C hoSS T/-w� // <br /> I. Application Information—PleasePrintAllInformation � is <br /> Property Owner's Name Parcel# <br /> t,. lVl t l Glle /t/R //, n C� �� 01•oyz-L 38 /8 zS� oScro3_ <br /> Property <br /> Owner's Mailing A/dd_ress Property Location p/ O <br /> / ! /OD 3 - tos-r-" J(�r s Govt.Lot-3---- ^t _ <br /> City,State Zip Code Phone Number _7 y,, '/., Section .>J <br /> 4 s+ s v✓► s-s o 3 Iola 9/1-3639 T30 N R uclE orT1'1 <br /> 11.Type of Building(check all that apply) Lot# r� <br /> N'1 or 2 Family Dwelling-Number of Bedrooms_3 Subdivision Name <br /> Block# <br /> ❑PubliOCommercial-Describe Use <br /> ❑ City of <br /> D State Owned-Describe Use CSM Number D Village of _ <br /> IVITownof j. 1VQ9 t ✓-er <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. D New System Replacement System D Trcatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> B- D Permit Renewal D Permit Revision D Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner - <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> D Non-Pressurized In-'hound D Pressurimd In-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> KHolding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dis ersaBTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Am Required(sf) Dispersal Area Proposed(si) System Elevation <br /> �VI.'Tank I� Capacity in Total #of Manufacturer u <br /> Gallons Gallons Units g c$ <br /> New Tanks Existing Tanks o u v m <br /> 0.U in t rn ii rD P, <br /> Scpci Holding Ta X ( (fid ester X <br /> Dosio,Cham er r` <br /> VII.Responsibility Statement- I,the undersig d,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI tuber's Signamr MP/MPRS Number Business Phone Number <br /> g.p <br /> _[S �oe r pe r 7r f 566$bo� <br /> Plumbcr�r s�Address(Street,City,State,Zip Code) I ,� / �/ t�Q� <br /> 70 •f y� � -D V�e6y4-e . CV ' <br /> VIII.Count /Department Use Onl <br /> Approved ❑Disapproved Permit Fee <br /> /''�I Date I�ss/ued/ Issuin a ignature <br /> D Owmer Given Reason for Denial $ 37i/ 5 ; ,' 47 2dt <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> 7(te 5t�e tr / frokc46el Ebe. <br /> o wgk6 Este F/apaL/�o oP /�t1ib cocoa arC6 oa, dee Fwr Iw foa <br /> tai <br /> G l,y defied Augad R, BF6 <br /> 5bite, , ".Limr"i ,ebtr A&F&Prrw ebb 6w IKArc• Caw l <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in z 11 inches iv size <br /> SBD-6398(R.02/09)Valid thr r 02/11 <br />