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COt1YYl@fC@.WI.gOV Safety and Buildings Division County <br /> 201 W.Washington Ave.,PA.Box 7162 II 6 w ele-fr" <br /> �y f i seo n Madison,WI 53707-7162 Sani�tatry P mit Number(to be filled in by Co.) <br /> oegrtmerrt,psi ommerce 7t 59a <br /> Sanitary Permit Application State Trans coon Number (� <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to theaPNoP governmental <br /> overnmental <br /> V <br /> unit it required prior rt obtaining a sanitary permit Note: Application roma for state-owned POWTS are Project Add ss(if different than mailing address) <br /> submitted m o <br /> the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1 m),Stals. '3 O y s'' -bd✓L /� 4)'e.LA Bcation Lrformation-Please Print All Information <br /> Property Owner's Name -� t Parcel# .. <br /> Tout Alc 6" 0It Sol/7 ad 4aa <br /> Property Owner's Mailing Address Property Lo 'on <br /> 93.s Or 'e.y /�,/ Govt.Lot <br /> City,state Zip Code Phone Number Y Yy Section 17 <br /> (3e e r t /M A/ urns e 3 CX/- S,BY _ /O/,f (circle one) <br /> T N; R /-f E or® <br /> IL Type of Building(check all that apply) Lot# I <br /> ®1 or 2 Family Dwelling-Number of Bedroom, .3 Subdivision Name <br /> Block# <br /> ❑Public/Commemial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village <br /> V.I(0 f. (3- <br /> Town of s..1Jr <br /> IIL Type of Permit: (Check only one boa on lire A. Complete line B if applicable) <br /> A. New System ❑Replacement system ❑Treatment/Holdir Tank tac®ent Ont ❑Other 'nation to Existing System Iain <br /> Ys ReP Ys B ReP Y 8 Y (explain) <br /> B. ❑Permit Renewal ❑Permit Reviioa ❑ Change of Plumber ❑Permit Transfer to New List Preview Permit Number and Date Issued <br /> Before Expnation owner <br /> IV.T of POWTS tem/Corn amartMevice: Check all that apply) <br /> N Non-Pressurited In-Ground ❑Pressurized In-Ground ❑A4Grade ❑Mound>24 in.of mailablesoil ❑ Mound 24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(expla' ) <br /> V.Disperstalfrreaftnent Area Information: <br /> Design Flow(gpd) Design Soil ApplicationRate(gpdef) Dispersal Area Required(at) Dispersal Area Proposed(a System Elevation <br /> Oso . 7 (04-7 1 6yg 9e6• o 9s, q <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units R <br /> New Tanks Existing Tanks <br /> 6 U '.n rn is.C7 ZL <br /> Septic or Holdbg Tank 0 1 0 /d 00 <br /> Dosing Chamber <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on them tacted plans. <br /> Plumber's Name(Print) Plumber's Sigmtue MP/MPRS Numb a Busmcas Phone Number <br /> R/c% k "-f / ,.Q eAO-4/s7 <br /> Plumber's Address(S city,state,zip Cade) <br /> .27760 //..- 'Y We,6str - WS" SYe95;-r <br /> VIII.C2untL/INquartument Use Only <br /> Appmved 11 Disapproved Permit Fee Date <br /> Daate Issued Issuing Ag <br /> ❑Owner Given Reasom for Denial <br /> $ �Jr// 9149 0-7 <br /> IR Conditions of ApprovaUReasons for Disapproval <br /> Much to complete pmnsfse the system and mdmk mum County only an paper mot ler than 9 Ors:11 Inch amsize <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />