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Aja <br /> eommeraewi.gov Safety and Buildings Division Country <br /> 201W.Washington Ave.,P.O.Box 7162 /t1 <br /> rilepiarbusont sconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.)of Commerm S 4 3 7 <br /> Sanitary Permit Application State Transection Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental IN <br /> unit is required prior to obtaining a sanitary permit. Note: Application farms for state-owned Pow is are Proje4f Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used secondary <br /> purposes in accordance with the Privacy law,s. 15. 1 m,Stater. <br /> L Application Information-Please Print All Information <br /> Property Owner's N e Paroel# p--7-03 _ -art l-/7--,2 - <br /> �Do 1dS MIC iCVC SLdu 0�- 000 - 6 � �6Uc� <br /> Property Owner's Mailing Address Property Location <br /> +e o)�/ a✓ Govt.Lot <br /> City,State 1 { Zip�C[ode �7 Phone Number �l n I Yy �Yy Sectimt <br /> ed <br /> e-�/ C.. GJ S ! 93 / CS 17 � f+<t� (circle one <br /> II.Type of Building(check all that apply) Lot# T_ N; R /-7 E a ,' <br /> 2 Family Dwelling-Number of Bedrooms —� �- Subdivision Name <br /> Block# <br /> ❑PublidCommccial-Describe Use <br /> ❑ City of � <br /> ❑State Owned-Describe Use �� CSM Number ❑ Village of r- <br /> �' T Town of <br /> 1IL Type of Permit: (Check/only one boa on line A. Complete linell if applicable) - <br /> / _s a <br /> `L ❑ New System t11ftiacement System ❑TreatmenUliolding Tank Replacement Only L1 Other Modification to Existing System(explain) <br /> B. ❑ Peanut Renewal ❑ Permit Revision ❑ 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 onendDevice: Check all that apply) <br /> Tial-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in,of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Disposal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dill rsal/Tratmtmt Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Disposal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> Sb 1 -7 1 6/y3 16s a q3./ <br /> VL Tank Info Capacity in Total #of Manufachuer <br /> Gallons Gallons Units ° v <br /> New Tanks P.wating Tanks ° v L <br /> 'w <br /> ,!, tie, Yn C7 <br /> Septic or voiding rank <br /> Dosing Chamber <br /> VII.Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attacked plans. �^� / <br /> Plumbzz�er (Prim) H / �/0/� Plumber's Signature- 2 2 7 to / / BusinessMPIMPRS Number �j / �� (- <br /> Plumber's Address(Street,City,State,Zip Code) (/�lJ) �i <br /> J v S / - e...-J <br /> VIII County/Department Use Only <br /> R/Approved ❑ Disapproved Pemtit Fee Date Issued Issuing Pau- <br /> a r� <br /> ❑ Owner Given Reason for Denial 326 o /L <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 812:11 inches in alae <br />