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commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 UµV.N-e <br /> tisconsin Madison,WI 53707-7162 Sanitary Permit Numbe ( be filled in byepartmem of Commerce `40, ( 7 t( <br /> Sanitary Permit Application Slate Tran 'onTNumy/��r <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �� VIQ.t/I <br /> unit is required prior to obtaining a sanitary permit. Note: Application fomes for state-owned P w lb 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 /> sea in accordance with the Privacy Law,s.15. 1)(m),Stats. S/G y/r S y <br /> I. Application Information-Please Print AB Information <br /> Property Owner's Name ©C� Parcel# e'l•s/1,-ALIO-/ - <br /> .16 S e �o r. /e s #� OOa 15- 7o s-- p l>oaa <br /> Property Owner's Mailing Address Properly Location <br /> 6 3'O/ Creaky ^tie � <br /> City,Stateovt Lot <br /> Zip Code Phone Number Govt <br /> T„pe✓ 4mve /4h"jr /N Al 65076 Yh %, Section es <br /> 6s”/ -yS7- 7/�/ (circle one) <br /> IL Type of Building(check all that apply) Lot# T 4'0 N; R /,S E m�q <br /> I or 2 Family Dwelling-Number of Bedrooms - ' / Subdivision Name <br /> Block# 4 SKYIJ6HTG�EIJ AoAa{-i--b UI <br /> ❑PublidCommemial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSMNumbm ❑Village of <br /> 8 Town of JLt M <br /> III.Type of Permit: (Check only one boa on role A. Complete line B N applicable) <br /> A. .�New System \ <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Rem m al ❑Permit Revision ❑ Change o£Plumber ❑PermitTransfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> rI-V/.T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> iA Non-Pressurised In-Ground ❑Pressurized In-Groumd ❑ At-Grade ❑Mound>24 in.of suitable sod ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design New(gpd) Design Soil Application Rate(gpdsf) ispers <br /> Dal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 I . -7 NF 5 L/3,1 `?D'00 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tacks Existing Tanks V o <br /> GU in m y ii (7 R. <br /> Septic or Holding Tads <br /> Dosing Chamber <br /> VIL Responsibility Statement-I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prmt) Plumber's Signature MP/MPR! 1111 1 1Business Phone Number <br /> I V_5-e.5y <br /> Plourna 3 Address(russet,City,State,Zip Code) <br /> VIII.Cotm /De artment Use Only <br /> Approved ❑Disapproved Pera it Foe Date Issued Issuing ture <br /> ❑Owner Given Reason for Denial Sc�C-i7 444s/20r 2011 <br /> DC.Conditions of Appri val/Reasons for Disapproval <br /> Albch to complete plans for the system and submit to the County only to paper not has thio 8 in x Il hrehe-1.d. <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />