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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Zu me rt <br /> Madison,WI 53707-7162 ani Permit (t fled n b <br /> y )Iscon !n <br /> MpartsmM a comm.ro. O <br /> Sanitary Permit Application atamTransactlanNumber <br /> In accordance with a.Comm 83.21(2),Wis.Adm.Code,submission ofjhis form to the appropriate govemW <br /> men <br /> unit is required prior to obtaining a sanitary permit. Note: A i on forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide Truly be used for secondary VQ <br /> 2urposes in accordance with the Privacy Law.s.15.04(l m Stats. <br /> 1, A 1301iCAtitinInformation-Please Print 11Innformation MCR-1�y <br /> Property Owner's Name n_ w Parcel N <br /> OL - 9035-0/ 00 <br /> Property Owner's Mailing Address Property Location <br /> 3 Ll ao74 Lwig- NE Govt.Lot_ <br /> City,Stam Zip Code - Phone Number —" y, Y, Section <br /> e el "SGO) 54'Zq T 2 R circlWee on <br /> 11.Type of Building(check all that apply) - Lot s <br /> �.J I ort Family Dwelling-Number ofBedrooms, 13 _ 3 Subdivision Name <br /> L d PvhP�S <br /> ❑PubliUCommercial-Describe Use Block Y <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of. K <br /> Ill.Type of Permit: (Check only one bow:on line A. Complete line B if applicable) _ <br /> A. ❑New$ stem. <br /> Y ❑Replacement System . ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> 9. ❑Permit Revision ❑ Change of Plumber ❑permit Transfer to New List Previous Permit Number and Date Issued <br /> Owned <br /> ss POWTS S stem/Com onent/Device: Check all that apply) <br /> I <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground D. At-Grade ❑Mound>24 in.ofsuitable soil ❑Mound<24 in of suited5le soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVrrestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> Hao -7 6113 &SO > F2. (I � ' <br /> VI.Tank Info Capecity in Total g of Manufacturer <br /> Gallon Gallons Units B l <br /> New Tanks Existing Tsuke <br /> a V A h 7 a <br /> Septic or Haldlwg@� /DOO � _ <br /> Oo0 x <br /> Dosing Chamber <br /> Vll.Responsibility pStatement- 1,the lined,assume responsibility for allation ofthe POWTS shown on the attached plans. <br /> MCIM1 x7C <br /> P Pl ltp El EXCAVATION PI tuber's Sa tare MP M�R3yNumber Bus Tress Phone Number <br /> Plum set, µ o e) <br /> 7 <br /> II.Couna artment se nl <br /> pproved ❑DisapprovedSerra, F1ee� Date IsstrAJ.r-� lulu' Agent Signature <br /> C1Ownsr Given Reason fZDenialIX. Conditions of Approval/Reasons for Dsapproval <br /> PERM i I <br /> Attach to complete plane for the system and submit to the County only on paper not its,than s In a 11 Inehu Incite <br /> SBD-6398 (R 01/07)Valid ttuu 01/09 <br />