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eommereemi.gov Safety and Buildings Division County Q r P, f <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> tDopartismant iseonsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> of Co nnumme a I <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Prqect Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purpores in accordance with the Privacy Law,s.15.04(l)(m),Stats. AlI. A kation Information-Please Print All Information <br /> Property Owner's Name Parcel# �Il/ <br /> z nn Jot c1 at n j Cd0 N3(fl 07/00 <br /> Property Owner's Mailing Address Property Location <br /> 9/-7V /$rG CK ridre- Gan la Govt.Lot CJzl <br /> City,StaleZip Code Phone Number 'h, Y., Section /4 <br /> of e w pe k 1 e T-e M N . 3 47 75j— 9341- 3"30 0 ((crch:one)_ <br /> IL Type of Building(cdleclt all that apply) Lot# T 4eO N; R /6 E oIN <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms ^� Subdivision Name <br /> Block# <br /> ❑PubadCommercial-Describe Use <br /> ❑ CiTy of <br /> 0 State Owned-Describe Use CSM Number 11 Village of <br /> V,la- P. )21 Cy ryT..of epi*& <br /> 111.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. 0 New System 9 Replacement S stm 0 TrestimantilIGIding Tank Replacement Only Other Modification to Existing Systern(explain) <br /> H. ❑Pemu Renewal ❑Permit Revision ❑Change of Plnnnber O Permit Transfer to New List Pmvioua Pennit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com ment/Device: Check al]Out apply) <br /> Non-Pressurized In-Ground 0 Pressurized In-Groumd 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<yt in,of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Davice(explain) <br /> V.Dispersanreaftnent Area Infotmatim: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(et) Dispersal Area Proposed(at) System Elevation <br /> yS0 . 7 G-Y 3 6 S0 `3SG $y 6 <br /> VL Tank Wo Capacity in Total #of Manufacturer yy <br /> Gallons Gallons Unita <br /> New Tanks Furring Tmila it 4 <br /> rn m w iw c7 a <br /> Septic or Holding Tank /000 /p00 <br /> Dosing Chamber O 600 <br /> 1 f <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Ree-le h/a 1et. s 12ze ..Q Il JJ5Sdr1 7/s-ebb - 4/3'7 <br /> Plumber's Address(street,city,State,Zip Code) <br /> 776x7 ,a. 3s w< bsllsar W- <br /> VI1L Coup /De s rtment Use Only <br /> .Approved Disapproved ParmllFce Date Issued Issuing tmre <br /> D Owner Given Reason for Denial4� �b-Lute <br /> 1X.Conditions of Approval/Reasons for Disapproval <br /> Minch to complete plana for the sysnu and=limit to the Conray ody an paper rot les than 814 a Il IrcM in size <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />