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eommeree.wi.gov Safety and Buildings Division County <br /> i 201 W.Washington Ave.,P.O.Box 7162 ,,y r' <br /> 4t, <br /> seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by <br /> apartment of Commerce 5,3X2 e6 V t <br /> Sanitary Permit Application State/T/ra/gaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (/(7wt'kf� <br /> unit is required prior to obtaining a sanitary permit Now: 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 secondary <br /> purposes in accordance with the Privacy Law,a.15.04(1)(m),Stats. 3084/ �p�jpa.Ghti <br /> I. Application Information-Please Print All Information <br /> Property Owner's Nameh r_1_. `� Parcel N e 7- 63.14-W•/d=/7-.QO.f <br /> A3'{ �3'{ as•••v AW <br /> %-t)eh G i fir r .Spa IV e$#Sp n Co o ` I O( goes- -o/G®oo o3z 52)7 031' <br /> Property Owner's Mailing Address Property Location <br /> I p &AJ1s%vR o7 Govt.Lot� <br /> City,State Zip Code Phone Number 7E- y, �y, Section 7 <br /> yZ�l /y V -5 .3$/ (stock one) <br /> ImL.Type of Building(check all that apply) Lot N T /// N; R 1�E o(V <br /> to l or 2 Family Dwelling-Number of Bedrooms 5 Subdivision Name <br /> Block 9 <br /> ❑PubGdCommercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 11 Village of <br /> Vol. 1V A, 72 Ins Toomof Xwl-rj <br /> III.Type of Permit: (Check only one boa on fine A. Complete tine B if applicable) <br /> A. <br /> , New System ❑Replacement System ❑ TreatmentlHokiing Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Pemtit Renewal ❑Permi[Revision <br /> ❑ Change of Plumbef ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expvation Owner <br /> IV.Type of POWTS 3 stem/Com onent/Device: Check all that apply) <br /> .r Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Gude ❑Mound>_24 in,of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑OthcrDispmal Component(explain) ❑Pretreatment Device(explain) <br /> V. ersal/Trentment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> t2p- 1 . 7 (-v.7 64(,? 9/.00 9a• A7 <br /> VL Tank Info Capacity in Total k of Manufacturer <br /> Gallon Gallons Unita yq o'8 g <br /> New Tanks Existing Tanks 00� U �i a V <br /> [G U m <br /> Septic or Bokbng Tank /ems /ops / .f/L'at a✓ <br /> Dosing Chamber <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 MP/MPRS Number Business Phone Number <br /> �/c% /5/0 /c;„s /�• .f!,,,� sD�S/ lis-BGG- vir7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776o A/w _RS tvehs><N t*/r SS' Frf`f <br /> VIIL COMM /De arlmmt Use Only <br /> Approved ❑Disapproved Permit Fee Datelasued Issuing ture <br /> ,; /b❑Owner Given Reason fm Dental �5 e9 5ilaV <br /> IX.Conditions of Approval/Remems for Disapproval - <br /> Atech b eonpkle plan for the syrteu and subnft tothe County only on paper not tons then 8 to a 111rchea in sift <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />