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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave,P.O.Box 7162 i3kr n E <br /> isco n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be Filled in t y Co.) <br /> Department of Commerce 544) 440 <br /> O <br /> Sanitary Permit Application Slate Transaction Number �1 \ <br /> �} <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental N�x� evlef�(/ �f <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POW IS are Project Address(if diffsount than mailinj address) Q0 <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1)(m),Slats. of 7y8� Rer.ltt ��. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name ��jj '�//'y�� / Parcel# pT-Oil ^et'a/P'/ 33st'- <br /> oAn ,J�rf 4te 1 � lV l� -15-- 0(S—O fh 000 <br /> Property Owner's Mailing Address Property Location <br /> NNS G"rttnl�Ave ��. <br /> Gov[.Lot <br /> City,State Zip Code Phone Number yq Y., Section3 <br /> A6ariis A7A1 J:5 `101 —7 T 10Y49 N; R �bcrcle ,one ) <br /> IL Type of Building(check all that apply) Lot# ^ <br /> 1 or 2 Family Dwelling-Number of Bedrooms at <br /> V l Subdivision Name Mbef--& KaibeaS <br /> Block# .SU43-Of Devils Lae <br /> ❑ <br /> Public/Commercial-Describe Use <br /> ❑ City of <br /> 0 State Owned-Describe Use CSM Number q❑r Village of <br /> .L]Town of 6aNG(- <br /> IIL Type of Permit: (Check only one box on line A. Complete tine B if applicable) Qao_ -75— Di —aGp <br /> A. 0 New System p Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to ExistingSystem Y st <br /> (explain) <br /> B. 0 Pemtit Renewal Permit Revision ❑ Ch eofPlmnber Permit Transfer to New List Previous Permit Number and Date la =it <br /> ang ❑ <br /> Before Expiation Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> 1 <br /> Mon-Pressurised In-Ground 0 Pressurized In-Ground 0 Al-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dis ersaVTres, ent Ares Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(at) Diapersa],Auca Proposed(at) System Elevation <br /> 300 . 7 <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Unita y <br /> New Tank. Existing Tanks ,.�^„ a O L b <br /> Septic a Holding Tw& G Q OO <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sigmim MP/MPRS Number Business Krone N bei <br /> �,�Lc f/ap/c,•hs I�;rr.�.az��/ �s�s/ �%s-��a - y (s <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776 O Gf/eb-f <br /> VUL Coon /De armnmt Use Ont <br /> Approved ❑Disapproved ee Da$meaed Issuing t gnature <br /> ❑ Owner Given Reason for Doniajl ,7�5- <br /> 105v 24DID <br /> IX.Conditions of Apprwal/Remom for Disapproval <br /> Auseh m rompletrplan for the sys4m and suhmlt m the CouNy oNy an paper not km than a to s l l Irahn in size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />