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Commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 k n e H <br /> Madison,Wl 53707-7162 Sanitary Pen it Number(to be filled in by Co.) <br /> 'Wisconsinegmrtmorht«Cwehm.rca 53 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comma.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental l V 72-440 <br /> wit is required prior to obtaining a sanitary permit Note: Application forma for state-owned POWTS ane Project Ad&as(if different than mailing address) Ji <br /> submitted to the Department of Commerce. Personal information you provide may be wed for secondary <br /> purposes in accordance with the Privacy Law,e.15. 1 m),Stats. <br /> I. Application Information-Please Print All Information pA✓/e J(f <br /> Property Owner's Name parcel g <br /> Lore Nt(sd.1 0' - 57 00 /3 �jelD <br /> Property Owner's Mailing Address Property tion <br /> g14 q Pa ✓/c St. <br /> Govt Lot <br /> City,State Trp Code Phone Number <br /> '/s w, section /9s3o <br /> tuie6f><C✓ W-t- SNds3 7/.S- 567- el-fw T 410 , R /f�(crcE� <br /> IL Type of Building(check all that apply) .r Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms Or Subdivision are <br /> Bloch# <br /> ❑ <br /> OW PubadCommacial-Desaibe Use ❑Cityof <br /> LOT 1p <br /> ❑State Owned-Describe Use CSM Numbs ❑Village of <br /> C�; h) / , I vh ® Townof A1-'1AAd- <br /> IIL Type of Permit: (Check only one bo=on 1she A. Complete brae B if applicable) <br /> New System ❑y. Replacement System ❑TreatmmVHohling Tank Replacement Only ❑Oma Modif=tiou to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Trans to List Previous it Number and Date Issued <br /> Before Expnation Own. <br /> IV.Typeof POWTS 3 tem/Com menuDevice: Check all that apply) <br /> ❑Non-Pressurood In-Ground ❑Pressurized Io-Ground ❑At-Grade J3 Mound>24 in.of suitable sod ❑Monad< in ofsuinble soil <br /> ❑Holding Talc ❑Other Dispersal Component(acplam) ❑Prc1rwtment Device(expIain) <br /> V.Dinquersolrrreatment Ara Irdormation: <br /> Design Flow(gpd) Design Soil Application Rale(gpdsF) Dispersal Area Required(at) Dispersal Ates Proposed(sf) System Elevation <br /> 30a 9 300 33e/ <br /> VL Tank Isdo Capseity in Total #of Mameftcmrer <br /> Gallon Gallow Units <br /> New TanksTanksy o <br /> ceOi 38 wc�7 S <br /> Sepnc a F1oldrng Twilc Exedug/0 0 0 /OO e <br /> Doing Cheater <br /> 00 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the alt ed plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Nu Business Phone Number <br /> Rtele //o /erh,1 /i/ �iS�s/ 7/s-g6G yis� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 76 0 /uw y weds/,•r wT _5-Yff? <br /> VIIL ours /De artment Use Only <br /> Approved I ❑Disapproved Permit FF a Dam Issued Issum em Signa <br /> ❑Owoa Given Rcasonfa Denial S 3M,* <br /> -2J44b7 <br /> 1 94"A <br /> DL Conditions of ApprwaURema s tea Disapproval <br /> Attach to caspkfe plan for the sysks am mbnh tothe County only an paper ma leo•thm 8 in a 11 Inches hm she <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />