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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Sit rn t' IY <br /> 'Wisconsin Madisom WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> epartmem of Commerce 53e2 Z06 <br /> Sanitary Permit Application State Transaction N bur <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental t.l� U l" <br /> unit is required prior to obtaining a sanitary permit Note: Application forma 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 Priivacy Law,s.15.04(lxm),Slats. 3799 Zoon G/L <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name z Parcel# <br /> rte, J&ek.%6h Cern n th x and y.;, o/ oryep <br /> Property Owner's Mailing Address 75z S 4AICE ,Q4 Property Location <br /> 3(,% (o N.a rJ St. N.6 C-VDAW, WI s Ito Gurresr O vre/ in <br /> City,Sate Zip Code Phone NumberII ) <br /> ^rr' !t W(AYa Section / <br /> rvl /s /�Al SSy/� (circle one) <br /> T 10 N; R 15- Eorep <br /> IL Type of Building(check all that apply) Lot# <br /> ®1 or 2 Family Dwelling-Number of Bedroom 3 Subdivision Name <br /> Block# <br /> ❑PubadCommacial-Describe Use <br /> ❑City of <br /> ❑Sate Owned-Describe Use CSM Number ❑p Village of <br /> W Town of JaG/GdOh <br /> IDL Type of Permit (Check only one box on law A. Complete line B if applicable)0 _ _ <br /> A. ❑New System Replaccureirt System Treatment/Hold'mg TankReplacement Only Other Modif"ition to Existing System <br /> (explain) <br /> B. ❑Permit Renewal ❑Pe:mit Revaioa ❑ Change of Plumber ❑PermitTransferor New <br /> List Previous Permit Number and Date hated <br /> Before Expiration Owner <br /> IV.Type of POWTS shun/Com onmt/Device: Check all that apply) <br /> ry <br /> yy Non-Pmsurized In-Ground ❑pimauri ted Lr-Ground ❑Al-Cade ❑Mound>24 is of suitablesod ❑ Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑OtherDi prnat Compommt(nplam) ❑Retreatment Device(explain) <br /> V.Die ersaVTroahnent Arm Information: <br /> Design Flow(Spill Design Soil Application Ram(gpdsfl Dapenal AreaRequired(sf) Dispersal Arca Pro <br /> posed(at) I System Elevation <br /> ys-o S 9®G 900 93 .50 <br /> VL Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units gg ° <br /> New Tanks Et¢etmg Tanks $ is�a <br /> it y go A W 7 <br /> Septic or Holding Tank /e O O /DBO <br /> Dosing Chamber <br /> VIL 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 WINIPRS Number Business Phone Number <br /> Plumber's Address(Street,City,Sate,Zip Code) <br /> 7760 /./ 3-f Gt/e�Srler ttir SYSS� <br /> Vill.Coin Coin/'De armient Use Only <br /> Approved ❑Disapproved Parmit FFac Dae hsued Issuing AS ` <br /> ❑Owaer Given Reasonfor Denial s�.3'C.5 <br /> IX.Conditions of Apps o al/Reasoro for Disapproval <br /> Attach as complete plans for the system and subaa to the Conray a*on paper,out km than 8 to:11 inches In sift <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />