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eommereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 St4 rel 7V <br /> tiilDeparbrauntseonsin Madison,WI 53707-7162 Sanitary Permiit Nr other(m be filled in by Co.) <br /> of Commerce 5.4 j 05z' <br /> Sanitary Permit Application Slate Transaction umber / 1 � <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental �I \`J <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(it different than mailing address) V� <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 1 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. S/(o 3'7 014,' t <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name /! Parcel 4 p/L Z07 W_500 <br /> 00 <br /> kt n M,0,5 I'< l ( (} �� � 7 o7 o/d d vo So'7SOSoo3r 03/ova <br /> Property Owner's Mailing Address Property Location <br /> City,State Zip Code Phone Number - <br /> Yy _Y., Section <br /> �XCez/s/s✓ <br /> ,on Sr33 / (circle one) <br /> IL Type of Building(check all that apply) )) Lot k T��N; R Eo <br /> & <br /> m <br /> A I or 2 Family Dwelling-Number ofBedmoa rlr Subdivision Name <br /> Block N <br /> D Public/Commercial-Describe Use <br /> ❑City of <br /> 0 State Owned-Describe Use CSM Number D Village of <br /> Town of 161-/Z<O N <br /> IIL Type of Permit: (Check only one box on Ihte A. Complete line B if applicable) <br /> A. D New System p.le lacement System D Trestment/Holdin Tank R lace umat Duty 0 Other Modifica on to Existing S lain <br /> eP Y B eP Y B tem Ys (explain) <br /> B. 0 Permit Renewal ❑Pemrit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Penn Number and Date issued <br /> Beforo Expiration Owner <br /> IV.Type of POWTS System/Com onent/Device: Check all that apply) <br /> RNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>_24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 OtherDispersal Component(explain) ❑Preheatmmt Device(explain) <br /> V.Dispeessibrrmatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed storn Elevatio <br /> 300 I s-7 y,l Oe. 7 <br /> VL Tank Wo Capacity in Total N of Manufacturer <br /> GaRom Gallons Unica <br /> New Tanks Existing Tanks <br /> o, m ti R.0 a. <br /> Septic or Holding Tank ^7S-O 7Sp <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attach plots. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> dBS/ 7i6= S6G-�/�s'7 <br /> Plumber's Address(street,City,State,Zip Code) <br /> 7 76 o 3.5— we6sf�� tfJj S�g93 <br /> Vin Coun /De srtohent use only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing ignaturo <br /> ❑Owner Given Reason for Denial S 3W#"' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to eompkte plans for the system and subuW to the County only on paper rot km than 81x1 x 11 lashes basis <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />