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PD- <br /> COMM <br /> ommerceml.gov Safety and Buildings Division County1201 W.Washington Ave.,P.O.Box 7162 3K r n e1'(con sin Madisoq Wf 53707-7162ry,Iermums (b be fdled in by Co) <br /> rtmerrt of Commerce TO Sanitary Permit Application State Trannsaction Number <br /> .Comm.83.21(2),Wis.Adm.Code,submission of(Itis form to the appropriate governmental /9z 8cob <br /> or to obtaining a sanitary permik No[e: Application forma for atateowned POWTS are ProjectAddress(ifdifferenl than mailing address) <br /> epartment of Commerce. Personal information you provide may be used for secondary <br /> Linoses in accordance with the Privacy Law,a.15.04(lXm),Stats. <br /> I. Appliciltion Information—Please Print All Information /rr UkS$ G/� �pc• <br /> Property Owner'a Name <br /> / /f7 Parcel# <br /> "M R.Proll 725 BIS - 33,t0 - O� - '100 <br /> property Owner's Mailing Ad a Property Location <br /> /vys ly as sE <br /> City,Stale Zip Code Phone Number Go".L _ 1 �, SO <br /> 13u.��alo MN 5S- - s iA Section <br /> (circle one) <br /> IL Type of Building(dteck all that apply) Lot g T 3 9 N; R /G E or® <br /> 1 or 2 Family Dwelling-Number of Bedrooms------- Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSM Number ❑Villageof <br /> gToomof /V) +e s M oa/1 <br /> IDL Type of Permit: (Check only one boa on line A. Complete line B B applicable) <br /> New System ❑Replacement System ❑Treatmentdlolding Tank Replacement Only ❑Other Modification to ExistingSystem Y stem <br /> (explain) <br /> B. ❑Permit Renewal ❑Permit Revision a of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration Chang ❑Permit Transfer m New <br /> Owner <br /> lV.T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑pressurized ln-Ground ❑At-Grade ❑Mound>24 in,of suitable soil Mound<24 in of suitable soil <br /> U Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gll Dispersal Area Required(st) Dispersal Area Proposed(st l System Elevation <br /> 4_so • 9 VS 0 SD Z/ 97• // <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks g Ua <br /> b <br /> cf:V in m y iw r7 n. <br /> Septic or Holding Tank /000 <br /> Dosing Chamber /OOO <br /> 600 yae <br /> VIL 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 Numb" Business Phone Number <br /> Peck wejkln f /2,4-al "l <br /> Plumber's Address(Street,City,State,Zip Cade) <br /> 7760 .54 BS Gvebsfe S5'8s3 <br /> �V,IIIIL Coun /De artment Use Ont <br /> Id Approved ❑Disapproved Permit Fee Date Issued Issuing lure <br /> ❑Owner Given Reason for Denial S 375,, VANv, It/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Anal to romp ere plans for the system aM auburn m the County only an paper opt leas than a In x 11(acres in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />