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Ahlb commeree.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> 'Wisconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> epartmersl ex Cwnnnerce 4&0� 85 <br /> Sanitary Permit Application State Transaction Numbpper ' I <br /> In accordance with s. . m <br /> Comm..83.21(2),Wis.AdCode,submission of this form to the appropriate governmental /51 ,333 O <br /> unit is required prior to obtaining a sanitary pemnit Note: Application forma for state-owned POWTS are Project Address(if different than mailing address) w <br /> Submitted to the Department of Commerce. Personal information you provide may be used for secondary �k <br /> purposes in accordance with the Priv Law a.15. 1 �qq <br /> m),Stats. E v /s <br /> I. A lication Was <br /> ormation-Please Print All Information Or. <br /> Property Owner's Name Parcel# <br /> La Cow ! <br /> DOE VC?l Wlerk *Aodb-aY336of300 <br /> Property er's Mailvng a Property Location <br /> Govt Lot <br /> City,State Zip Code Phone Number 'VW Yy NR, Yy Section <br /> We,A �/T Sy S93 -7/S- f6G - X839 (circle once <br /> IL Type of Building(check all tint apply) Lot# T . -t- N; R�E o <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> 11 State Owned-Describe Uee <br /> CSM Number ❑Village of <br /> Town of Q4n40 <br /> IDL Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A. a•New S Stan ❑ <br /> Y Replacemrnt System ❑Treatment/Holding Tank Replacanenl Only ❑Other Modificative to Existing Sysf®r(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change ofPiumber ❑Petmi[Tramferm New <br /> List Previous Permit Number and Date Issued <br /> ]Before Expiration Owner <br /> IV.Type of POWTS stem/Com ent/Device: Check all that apply) <br /> ❑Nw-Praeurized InGmmd ❑Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil ❑Mound<ht in,of suitable soil <br /> ❑Holding Talc ❑Other Dispersal Compveent(explain) ❑Prehestmvet Device(explain) <br /> V.Dispersallryeaitment Area kdormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dupenal Area Proposed(sf) System Elevation <br /> yso . 17 1 so y So ey <br /> VL Tank Wo Capacity in Tow #of ManuGctuner <br /> Gallons Gallon Unita a U <br /> New Tads Pixistirg Tanks <br /> rt U 'm m <br /> Septic or Holding Tank /b00 /pm0 <br /> > chemmr (,00 ben <br /> VII.Responsibility Statement-I,the undersigned,assume responsib8ity for installation orthe POWTS shown on the attached plan& <br /> Plumber's Name(Print) Plumber's Signature MP/NIPRS Number Business Phone Number <br /> R/e,� Soto /e,.., ! /�cal.._� .1d S8s/ yes 8i0,- /.r 7. <br /> Number's Aridness(S City,Stam,Zip Code) <br /> 77 ee/ 3S we- scree W-T— S"1893 <br /> Vill.Cmoa /De arfinent Use Only Z� <br /> Approved ❑Disapproved Pamit Fon Dam Issued Deming ro <br /> i�natu <br /> 2to <br /> ❑ Owner Given Reason for Denial S goo a" r b 1-7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to eonplete plans for the arouse and a tusk to the County only an paper not les than 8 in a 11 inches in Sim <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />