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corntnerce.vvi.gov Safety and Buildings Division County <br /> i W.201 WWashington Ave.,P.O.Box 7162 u I'Pitt <br /> s c o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by <br /> Department of Commerce S5 1.2 OO <br /> Sanitary Permit Application State Tran tion Number <br /> In accordance with s.Comm.83:21(2),W is.Adm-Code.submission of this form to the appropriate governmental t k(21 cro <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stateowned 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 /> u oses in accordance with the Privac Law s. 15.04 1)(m,Stats. Z S/2/ 4 4 <br /> L A Iicationlnformation—PleasePrintAllInformation ✓ rhe <br /> Property Owner's Name Parcel# <br /> 0-7-®Yo-5-391 -4q—33 <br /> u wN Jau,)SA Coq -a 000 -Ols600 <br /> -Property Owner's Mailing AddressV Property Location <br /> I G,l,0 Pj N�-Si Syz <br /> (City,State Zip Code Phone Numbera E_y, �w Section -33 <br /> 1- -T/-" (circle on <br /> LS J Ps -_3-�N; R�E oro <br /> II.Type of Building( eck all that apply) Lot n <br /> fl ort Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSMNumber 11 Village of �,,/ 1 <br /> 19 Town of frV 1 SYS tt <br /> III-Type of Permit: (Check only one box on line A. Complete line B if applicable) DLI40 -_ <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration owner <br /> TV.Tye of POWTS S stem/Com onent/D"ice: Check all that apply)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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) Syatem Elevation <br /> 3_00 _ 7 <br /> I VI.Tank Info Capacity in Total #of Manufacturer <br /> i Gallons Gallons Units D v U v <br /> New Tanks Fx,,IIng Tanks <br /> 750 <br /> Septi w Fiolding'CaiJc <br /> wo <br /> 1P7 0Y_ <br /> Dosing Chanihcr <br /> VII.Responsibility Statement- 1,the undersigned,a some responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pr' t) Plumb 's SignatureMP/MPRS Number Business Phone Number <br /> Plulu <br /> j mber's Address(Street,City,State,Zip Code) <br /> 7 KS cam, V� J-D sir 4cj; - <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved $ermit FF//ee Datelssssuedd Issuing a ignature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I ENE <br /> OCT 1 3 2011 <br /> AMh to complete plans for the system and submit to the County..[yen paper not len than 8[a z it iucha I.sizeBl 1RNIM CiWNTY <br /> ZONING <br /> ,, -6393(R.02/09)Valid thru 02/11 <br />