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eommerceml.gov Safety and Buildings Division County <br /> ia201 W.Washington Ave.,P.O.Box 7162 3s,y N e f f <br /> seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(m be filled in by Co.) <br /> tDapartmasurt of Commeme 2 z/•f <br /> Sanitary Permit Application State Transaction Number \ <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form In the appropriate governmental o';Clt 4U 1C.0 <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondarypurpo <br /> sea in accordance with the Privacy Law,I.15.04(1)(m),State. N' �aam9) SQ1rG /en, vv <br /> I. A Frc ttion Information-Please Print AB Inform . It ` <br /> Property Owner's Name Pmcel <br /> .laser Dactil ;JJ 3 008 74S'o oil yO0 I �' <br /> Property Owner'a Mailing Address <br /> / Property Location <br /> 6/ /7,1h �r G N, Govt.Lot <br /> City,State Zip Code Phone Number I p <br /> Section /O <br /> /Yl Al rf O 7 S` T N; R (circle one <br /> GaILL�Type of Building(check all that apply) )) Lot# Q -r'Y <br /> Ol l or 2 Family Dwelling-Number of Bedrooms R 13 Subdivision Name <br /> Block# Lv Saihvt U/5"' <br /> ❑PubadCommercial-Describe Use <br /> z ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of /r�'� <br /> .9 Towa of Oew-ey <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable)O <br /> A. New System ❑Replacemmt System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification m Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ e of Plumber List Previous Permit Number and Date issued <br /> Cheng ❑Permit Trars,fer to New <br /> Before Expiration Owner <br /> rV.Type of POWTS S shm/Com menVDevice: Check all that apply) <br /> .M Non-Pressuraed In-Ground ❑Pressurized in-Ground ❑At-C de ❑Mound 124 io.of suitable soil ❑ Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.D"' ersaVl'reaOnmt Area Information: <br /> Design Flow(gpd) Design Soil Application Rare(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevati n <br /> 300 1 . 7 'YA9 r4't IF 93. 76 <br /> cj 1 . 77 <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons, Unit sip p� <br /> New Tanks Exating Tanks <br /> A <br /> Septic a Bolding Tank goo Boa <br /> / - , w )( <br /> Ibsirig Clamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation oflhe POWTS shown on the attached plans. <br /> Plumber's Name kl-nm) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 017760 Nw 3S UJe(�67tei� wt S4&rS3 <br /> VII Cauca /Deartntent Use Only <br /> IM Approved ❑Disapproved Permit Fees D?ate,I(ssued p Issuing A lure <br /> ❑ OwnerGiven Reaaonfor Denial S✓�✓� 34-)- �/ t <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to compete plow for the system and mbmb to the County rely an paper, at lea flan 8 Lt sit Inches Irish. <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />