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tcommerce.wi.gov Safety and Buildings Division Court y <br /> 201 W.Washington Ave.,P.O.Box 7162 , <br /> iseo ns i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 53Z 1 p I v <br /> Sanitary Permit Application State Trans tion/Number <br /> w <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 4'L /'QUI BoJ w <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stale-owned POWTS are Project Address(ifdifferent than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04 I m,Stats. <br /> L G <br /> Application Information-Please Print All Information �- <br /> Property Owner's NameI Parcel# <br /> 33(q I <br /> Property Owner's Mailing Addre Property Location <br /> 9f !L C/' lJ/,Qr,J p( N1 G Govt.Lot 31 <br /> City,State Zip Code Phone Number <br /> �) /- 7_7916-77g1S '/., '/., Section 16 <br /> ?T/9 /U O U e-it— /7) A) SS 3 / 16-5 m cle one <br /> _� <br /> rI-I�.�Type of Building(check all that apply) 3 Lot# <br /> T N; R E di <br /> pJ+or 2 Family Dwelling-Number of Bedrooms za;� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> -`� El city of �- <br /> 11 State Owned-Describe Use CSM Number El Village of <br /> V/0 <br /> ZZ own of \ /YC 6'iJ <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if appli able) <br /> A. ew System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 13 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> Y11l"Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(grid) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> 1 -7 6V3 6.5 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks $ o .. <br /> 0 2 ffi g A <br /> c` U vi N h W.. 0 d <br /> Septic or H<Idivir?,i kG- <br /> Dosing Chamber <br /> VII.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 /> uAsA/1'17 -7 .4 8C <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Count'/Department Use Only <br /> Approved D Disapproved Permit Fee Date Issued Issuing Age re <br /> ❑Owner Given Reason for Denial 9& ! <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than a in x 11 inches In size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />