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commereewi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 f- <br /> isconsin Madison,WI 53707-7162 Sanitary prmitNumber(to befilled inbyCo.) ( t <br /> Department of Commerce J� )f,I.,I M <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental — 3J 2 <br /> unit is required prior to obtaining a sanitary permit. Note: Application fortes 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 secondary ,/ (' <br /> purposesin accordance with the Priv Law,s.15.04 1 m),Suits. <br /> J�• / v \1l <br /> L Application Information-Please Print All Information 2 J�iLi tc _ o <br /> Property Owner's Name Parcel# C <br /> Property Owner's Mailing Address Property Location <br /> A/ -e� • GOVL Lot_ _ <br /> City,Smt�e�j Zip Code Phone Number y., Section <br /> 0✓Y2^ S fr 1S�— 83 (circle one <br /> 11..Type of Building(ch ck all that apply) Lot# T..�o_N; R_��E <br /> L71 or 2 Family Dwelling—Number of Bedrooms 3 �.____ Subdivision Name <br /> Block# <br /> D Public/Commercial—Describe Use Block 11 City of _ <br /> D State Owned—Describe Use Glib I' t �( U Village of / <br /> L� u Towo of �J®N <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 0 q_nIQ —n�S <br /> A" D New Systan Replacement System D Treatment/Holding Tank Replacement Only ErOther Modification to <br /> B- ❑ Permit Renewal ❑Permit Revision D Change ofPlumber D Pcmit Transfer to New v P it Num rend Date Dss d <br /> iim/9� <br /> Before Expiration Owner <br /> IV.Tviae of POWTS S stem/Com onent(Device: Check all that a 1" <br /> O Non-Pressurized hi-Ground R'Pressuriud In-Ground D AKhade D Mmmd>24 is of suitable soil D Mound<24 hr,of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D pretteatmerA Device(mpla n) <br /> V.Dispersal/Treatment Arm Information: --Z <br /> Design Flow(gpd) Design Soil Application Rate(gpdsi) Dispersal Arca Required(sf) Dispersal Area Proposed(sr) System Elevation <br /> Ysa Goo -r 1. ,— <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanksc 3 <br /> U .. u Y <br /> 3 a d <br /> U 2 <br /> Sep is or Holding Tank <br /> 0 1 W Gl6' ✓ <br /> Dosing Chamber Zs•� <br /> Y <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature W/MPRS Number Business Phone Number <br /> Plumber's Address Strect,City,State,Zip C e) <br /> it S� O <br /> VIII.County/Department Ose Only <br /> ®Approved D Disapproved Permit Fee DDate7IIssued Issuing Age i stun <br /> 11Owner Given Reason for Denial $ 3g, 09 /JtMe ;519 / <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper witless than a in x 11 inches in sine <br />