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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 JIANN ew <br /> tisconsin Madison.WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 5 D <br /> Sanitary Permit Application Sate Tra/nsaction/NumbeQr <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental IAC <br /> 1 �� .V l Gw <br /> unit is required prior to obtaining a sanitary permit. Note: Application forma fm state-owned POWTS are ProjectAddress(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for seconda" ^ �'] <br /> sea in accordance with the PrivacyLaw,s.15.04(t)(m),Sorts. A q 94•f"Al//1 C rV L I/�M <br /> L A Bcatim Information-Please Print All Information <br /> Property Owner's Name -{I�' Parcel# 0703AA 4/ <br /> GD ,�fl ODO_O/A mid <br /> Ropety Owner's Mailing Address &r Pmpety Location <br /> / O$76 - !nFA St N ' <br /> Ci state - Govt Lot <br /> city, Zip Code Phone Number �`�����')� �������77 <br /> �:J ti ys_(�y5 Section 36 <br /> Sfr��a✓A�t✓ M/✓ SS08at (cncleone <br /> IL Type of Building(check all that apply) Lot# T ��N; R E o(9 <br /> 1 or 2 Family Dwelling-Number of Bedrooms y 1 Subdivision Name <br /> Block# <br /> ❑PublidCommereial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSMNumber 3870 ❑Village of <br /> V.a2- 79' Town of f rJJ <br /> IIL Type of Permit: (Check only one box m line A- Complete tine B if applimble) <br /> A. JK New System y ❑Replacement System ❑Treatment/Hokling Tack Replacement Only ❑ lNlter Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Own". <br /> W.Type of POWTS S stem/Com ment/Device: Check all that appW <br /> X Non-Pressurized In-Ground ❑Pressurized hr-Gmund ❑ At-Grade ❑Mound>24 in.of suitable sod ❑Mound<24 in.ofsuitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Retreatment Device(explain) <br /> V.Dis ersid/Treahuent Area Informatim: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area R uucd <br /> P� eq (at) Dispersal Area Proposed(at) System Elevation <br /> 600 • 7 8S7 fV'G ev <br /> VI.Tank Info Capacity in Total #of Ivfanufactu,er <br /> Gallon Gallon Units s3 y <br /> New Tanks Exiating Tanks je C u b W $+ <br /> Septic w Holding Tads /d 5-17 /d.r0 <br /> ✓/c <br /> Losing Chamber / w..- <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plan& <br /> Plumber's Name(Rin[) Plumber's SSiignaturee ,�/ MP/MPRS Numb" Business Phone Number <br /> /G/G �b r�'r'a J 'u�a.�.eP' /7' <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 7 6� r.. � livob s7/ti� G✓�'SSa�9.2r <br /> VIIL Coun /De artmmt Use Old <br /> +Approved ❑Disapproved Pcmrit Fee Date Issued Issuin Sign <br /> ❑Own"Given Reason for Denial S �� 8.�✓1 �l(� ` <br /> IX.Conditims of Approv utteasons for Disapproval <br /> Attach w complNe plain for the rystem soil wbmll btk Courcy wily m paper ort lea them a 1a 111 Inches In she <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />