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CoRHnerCeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 (3tw r n 2 <br /> yf i seo n s i n Madison,WI 53707 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce S 3 11 <br /> t 1 <br /> Sanitary Permit Application State TransactionN ber �J <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental I ie <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if diffttent 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,s.15. 1)(m),Stats. 3GrOu H 4�1Y ps 4 <br /> L Application Information-Please Print AB Information <br /> Properly Owner's Name Ao+3 <br /> Cy/Q Farm# p�' O 3'Ad y/76' A 7,f /J'TeYCsa „ �enn wti I-tn Y76 bYA,V06 <br /> Properly Owner's Mailing Add.... Property location <br /> O. f/ 0.G u w v eQ /'J A f' 11 Govt Lot <br /> City,State Zip Code Phone Number7 <br /> A Y., Section <br /> L/.o /G /Y//V SS"O//t/ (circle one) <br /> IL Type of Building(check allthat apply) !' Lot# T 4/ N; R /S E or(V <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms T 7-2 Subdivision Name <br /> Block InneWav on ors /d', <br /> ❑Public/Commeroial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSM Number 11 Village of <br /> Town of <br /> Ill.Type of Permit: (Check only one boa on,lime A. Complete tine B if applicable) _ <br /> A. <br /> ❑New System RrReplaeement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision <br /> ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> ,IV.Type of POWTS S tem/Com anent/Device: Check all that apply) <br /> ,urNon-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable sod O Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVrireatiment Area Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> Goo • 7 es7 tet. 9 S/• 0 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> GallonGallons Units o 2 ° v <br /> New Tanks <br /> Existing Tadrs o 0 'w <br /> t� U in e,, res w C7 C4 <br /> Septic or Holding Tank <br /> Dosing Clamber <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> /2, e-k Hs lei n f All SSs1 7/S• 8G< <br /> Plumber's Address(Street,City,,State,Zip Code)/-'/. <br /> VII Coun /De artment Use Ont <br /> Approved ❑Disapproved Pemr2i[Fm�/�j Date Issued Issu' A Signature <br /> ❑Owner Given Reasinfor Derail 8✓ ,J' !/,p! /U�I�VIQi�rd ' <br /> IV-Conditions of Approval/Resisom for Disapproval <br /> Athch to complete plans for the system sod=limit to the County only on paper rat Ism ams a In x Il Inches in she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />