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COR1DmerCe.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O. Box 7162 :q /�/J e- <br /> Madison,sconsin Madison,WI 53707 7162 Sanitary Permit Number(to be filled in by Co.) <br /> epartment of Commerce <br /> Stale Transaction Numberf11Sanitary Permit Application 'UJith s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental -- <br /> prior to obtaining a sanitary permit. Note: Application forms for slate-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you rovide may be used fo secondary <br /> ur uses in accordance with the Privacy Law,s. 15.04 I (m),Stals. _ _ /6 b H#.� M✓< .fl� <br /> I. A Ifcation Information-Please Print All Information I - ''—I - I� <br /> Prop Owner's Name ¢T�Ye- Parcel <br /> 2 l6 3 C)r c3 <br /> Pr c Owner's Mailing Address T n �ia, / "1\�e Property LocationG.-T <br /> Govt.Lot__q__ p / <br /> City,Stale �xnp_f�,,,1�/V.H_ Zip Codc�&7 Phone Numbcr y,,_'/., Section <br /> 1 '�-�Kirt W� circle one <br /> --- Lot 4 <br /> Il.'rype of Building(check all that apply) - ----- ------ <br /> Subdivision Namc <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms <br /> Alock q -� <br /> 9fublic/Commercial -Describe Useg �m_Q: y <br /> .�- ❑ Cit Of <br /> -___ <br /> CSM Number El Village of <br /> U State Owned Describe Useq )j��wn of <br /> ❑I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> Ll New System cut System TrcatmenUl folding'fank Rcpl lccmem Only _ U Other Modification to Fsuning System(explaot) <br /> List Previous Permit Numbcr and Date Issued <br /> B. U Permit Renewal ❑Permit Revision ❑Change of Plumber U Permit Transfer to New <br /> Before Expiration Owac1 - _ 4D <br /> lrrryyyV.Type of PQWTS System/Component/Device__L heck all that apply)__ - __ (�.O-1. _ -. IJ5_ -1!2 <br /> rp.rvon-Pressurized ln-Ground ❑Pressurned In Ground U At-(oade ❑ Mound!24 in of suitable,.it U Mound 124 in of suitable sod <br /> U lioltling lank U Other Dispersal Component(explain) <br /> ❑Pretreatment Device(cxplain)-. . <br /> V.Dis ersalffreatment Area Information: _ ---- "-- <br /> Designn Flow(gpd) Design Soil Application Rale(gpdsl) TDispco al Arca Rest u (sQ Dispersal Arca Proposed fs0 System Elevation- - — <br /> �6 // <br /> VL Tank info Capacity in qat ManufactureroGallons v New Tanks Existing Tank 9 0 & la <br /> '7ber _-. ___ _-- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Signature MP/MFRS Number Business Phone Number <br /> VNamcint 8 ZZ��// �T / %��b <br /> or— <br /> (Street,City,State,Zip Code) <br /> artment Use Ong_--__ __ -__. Permit Fee Ualc Issued Issues Agent Signature <br /> Disapproved �¢��7yey„� _�/�Owner Given Reason for Denial �-"�_v_,_�_ _�__I_ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> -- - Annch so complete plans for the system and submit m the Cnnnty only on paper not less than 8 112 x 11 Inahes in sire <br /> SBD-6398 Ti.01/07)Valid thru 0l/09 <br />