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eommerceml.gov Safety and Buildings Division County <br /> F201 W.Wasltington Ave.,P.O.Box 7162 13 6&r n e <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) 1 , <br /> Deparlmerd of Commerce 5z / K" W <br /> Sanitary Permit Application State Transaction Norther <br /> In accordance with e.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental <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) o f <br /> submitted to the Department of Commerce. Personal information you provide may be wed for secondary 1 <br /> purposes in accordance with the Privacy Law,s.15. 1 m,Stats. �.S-O 9S Gib ss9 .�t y'/l n Q <br /> I. A Station Information-Please Print All Information <br /> Property Owner's Name <br /> Parcel k <br /> �ar Lr,t Ger Kc L%U:#335a5 018 J33s'_ pd �! 1 <br /> Propedy owner's Mailing Address Property Location <br /> 7 .5 � Z3rd SI`• Govt Lot �l Q65G (03(0/3 <br /> City,State Zip Code Phone Number <br /> Section <br /> La G r0 S.5 f✓ Z Sff (e 0 ( (ehcleone <br /> O <br /> I��(L( Type of Building(check all dint aPP1Y) 1 tut# T -3g N; R <br /> CF 1 or 2 Family Dwelling-Number of Bedroom , q 0- 709 Subdivision Name ()'7-0j <br /> 35-5 <br /> ❑Pub]idCommercial-Describe Use Blockk -05-0 - 01700 <br /> ❑City of <br /> ❑State Owned-Describe Use CSMNumber ❑Village of <br /> Town of /YI r?Err o N <br /> III.Type of Permit: (Check only one boz on Zine A. Complete One B if appBcabk) <br /> A. ❑New System ,�Replacemrnl System ❑Trea�ent/Holdin Tank tacement <br /> 8 Bep Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ (,'tangs of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS stem/Com oneraVI evice: Check all that apply) <br /> ❑Nor-Pressurized In-Ground ❑Pre urized hr-Ground ❑ At-Grade ❑Mound>2A in.of suitable soil ❑ Momd<24 in of suitable soil <br /> Holding Tank ❑Other Dispersal Component(expo) ❑pretreatment Device(explain) <br /> V.Dis ersall7'reatnent Area Information: <br /> Design Flow(gpd) Design Soil Apptcatior Rate(gpdst) Dispersal Area Requited(at) Dispersal Area Proposed(of) System Elevation <br /> VL Tank Info Capacity in Total N of Manufacturer <br /> Gallon Gagoro Units co <br /> New Torka Erdffing Tanks do to <br /> Septic or Holding Tank „Slee, C,- <br /> Dosing <br /> JDosing chamber <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sigmhae MP/MMS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> t-t-r —s-4' s-93 <br /> VIII County/Department Use 0111 <br /> Approved ❑Disapproved Permit Fee Date Issued( Issuing Ag r <br /> ❑Owner Grven Resson for Deniil $375 R7Me r o4 <br /> DC Conditions of Approval/Reasorm for Disapproval <br /> Attach to eaopMe plum forth sY+tas and sabot to the CoumY ady err paper mot les than 8 in x 11 Imelas In sire <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />