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commerceml.gov —Safe and Buildings Division County 201 W. w1 <br /> shington Ave.,P.O.Box 7162 !+/V t? <br /> ,�f iseonsin Madison,WI $3707-7162 Sam ilNumbe (obefilledinbyCoJ <br /> Department of Commerce us"Y " N- <br /> Sanitary Permit Application State T ction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of a is form to the appropriate governmental ---0— <br /> unit is required prior to obtaining a sanitary permit. Note: Applicatim forma for state-owned POWTS are <br /> Protect Ad rase(ifdifferenl than mailing address) <br /> submitted to the Department of Commerce. Personal information yo provide may be used for secondary <br /> eee in accordance with the Privacy Law,s.15.114(1)m),Stats. rr1� <br /> I. A Plicanon Information-Please Print A"formation 5?0 '5. Y&Ww &M "+J <br /> Property Owner a Name S ParcelHo OZO•j-i/O'/b'07-5'/S•$Bo•o5 oce <br /> c <br /> r /o W oaa 9/�S os3 <br /> Properly Owner's Mailing Address / �� Property Lacation L�-3 <br /> 3 S��' C o v e Govt.1 Lot [.-& <br /> City,sgtate s, <br /> F ( Zip Code Phone Number/ y.`-- '/` <br /> Saclion 7_ <br /> 763-786'-b%$O z ,.(circle o <br /> IL Type of Building(check all that apply) Lot H T_ -.-. N; R�b E o(W) <br /> 1/kcr 2 Family Dwelling-Number of Bedrooma -_ �I 3 Subdmision ame c <br /> Block a 10-ioV Cr IA1 $ l <br /> ❑PubadCommercial-Describe Use <br /> �_- City of <br /> CSM Number <br /> ❑ <br /> State Owned-Describe Uae 'P"'a''n of�-�--�-� �---- <br /> Village o <br /> a_ Lr—J <br /> IIL'Type of Permit: (Check only one boz on line A. Complete • e B if applicable) <br /> A. <br /> System ❑Replacement System ❑ Trwtmrn olding Tank Replacement Only ❑Other Mo�l�cation to Existing System(explain) <br /> B- ❑ Permit Renewal D Permit Revision ❑ Change of lumber ❑Perm it'transfer to New List Previmxs Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWTS S stem/Com onent(Device: Check all th t apply) <br /> 0-Nom-Pressurized In-Ground D Pressurized In-Ground D At-Grad D Mound?24 in.of suitable soil D Mound<24 in,ofsuitable soil <br /> D Holding Tank D Other Dispersal Component(explain)__ D Pretreatment Device(explain) <br /> V.Dis ersal/Creatim tArea Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal a sed(e System Elevation <br /> Yso , 7 Y� 6 96 <br /> VL Tank Into Capacity in '1 tat Hof Manufacturer <br /> Ganong G ons Units u <br /> New Tanks Foisting Tanks cg$ 'p <br /> Septic or Rd O rn °' rn w c5 d <br /> ISosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsi ility for installation of the POWTS shown on the al ch ed plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRs Numbs Business Phone Number <br /> cue a <br /> Plumber's Address(Street,City,Stals,Zip Code) <br /> �6xsiY <br /> VIIL Coun /De artment Use Ont <br /> Approved D Disapproved Permit Fee Date I sued Issuing Signature <br /> g 2 � T lllL <br /> ElOwner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plate for tsntem and whir to the County mdy m paper mt lee than s t2 z II Irchn In slu <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />