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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 �W✓nzf� <br /> iseonsin Madison,WI 53707-7162 Sanitary Perm <br /> Number(to befilled in by Co) <br /> Department of Commerce Sanitary Permit Application State Tranaan Nnmber /In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of)his forth to the appropriate governmental : V v <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address( than mail ing address) N <br /> submitted to the Department of Commerce. Personal information you provide may be used fo secondary <br /> u oses in accordance with the Please <br /> Law,S. 1 m Slats. <br /> I. Application Information--Please Printt All All Informafion _ lZ!{? Yri'r.r.qs_ �,rty,E�vvV <br /> Pro perry Owner's Name Parcel# <br /> IftkL£5 whk GS (IREwKS f-V IIV106 7f37-) 07,q- '7035-0[Soo <br /> Property Owner's Mailing Address Property Location - <br /> 333.1 2o7 t�` L-hn£ Govt Lot <br /> City,State Zip Code - Phone Number _y, _yy Section _�_ <br /> LLTHPI 1 In - S56 6) (z(Z— 2bZ E;474 T 3rl N; F r4 <br /> �cucic of <br /> 11.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Nam( <br /> Block# J 51G nes Scours♦ <br /> ElPuPublic/Commercial-Describe Use L-D City of <br /> CSM Number D Village of <br /> El Sure Owned-Describe Use _ <br /> .0 Town of i?LA,SV_ <br /> II1.Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> A. New System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification ttExis[ing System(explain) <br /> B. 0 Permit Renewal D Permit Revision [I Change of Plumber List Previous Permit Numhr and Date Issued <br /> g ❑Permit Transfer[o New <br /> Before.Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> jX Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in.ofsuitable soil D Mound<24 in of suitable sol <br /> ❑ Bolding Tank D Other Dispersal Component(explain) -El Pretreatment Device(explain) _ <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> o . l 6`43 G5 2 137..tor Z s. tot <br /> N'I.Tank Info Capacity in Total q of <br /> Manufacturer <br /> B <br /> Gallons Gallons Units <br /> New Tucks Existing Tanks U y - <br /> °' o <br /> Septic or Fieldtaa.ivtk- <br /> ooU IUov l llft�aJ <br /> Uosing Chunbcr, - <br /> VII.Responsibility Statement- 1,the undersigned,assume responsi lity for installation of the POWTS shown on the attached plans. <br /> PI MOIR. t'l l� 8t EXCAVATION I,I%T guu Signature, MP/MPRS Number Business Phone Number <br /> i -tic J y [S) G35 71�L <br /> PlumXr Mftnt'Wt <br /> layr o e) ' <br /> VI .Cour a artment see4nl <br /> Approved D Disapproved <br /> Permit Fee Dale�Is[sued QQ Issuin A tSignatu <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of ApprovabReasons for Disapproval <br /> Attrth to complete plum for the ,are.end submit to the County only on paper not leu than a in x 11 inches in size <br /> SBD-6398(R.01/07)Valid than 0009 �� Q <br />