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commerce.wl.gov Safety and Buildings Division County <br /> E201 W.Washington Ave.,P.O.Box 7162 t~✓n e <br /> iseo n s i n Madison,WI 53707 7162 Sanitary Permit Numb"(te be filled in by Co.) <br /> l)epartmmrd oI Commerce sz ��T <br /> Sanitary Permit Application State Transaction Number <br /> -� <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of time form to the appropriate govemmrntal <br /> unit is required prior to obtaining a sanitary permit. Nom: Application forms for state-owned POWTS are Project Addresa(if differeat than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> puMses in accordance with the Privacy Law,s.15.04(1)Lm),Stats. / <br /> L Application Information—Please Print All Information �e✓,SO si /7�' <br /> Property Owner's Name Parcel# - <br /> oA84 HO r4 U 4 CA ono e!/ ,ee <br /> I <br /> Property Owner's Mailing Address Property Location <br /> if g8 Ga✓$O h !? Govt.Lot <br /> City,State Zip Code Phone Number N�)/Z M <br /> �6 Yy Section <br /> s ens✓ �^'Z -T49671 T a/O N; (circle <br /> IL Type of Building(check all that apply) Lot# <br /> J9 1 or 2 Family Dwelling—Number of Bedrooms 7 Subdivision Name <br /> Block# <br /> 0 Public/Commereial—Describe Use <br /> ❑City of <br /> ❑Stam Owned—Describe Use CSM Number 0 Village of <br /> ®Town of <br /> IIL Type of Permit: (Check only one bout on line A. Complete line B if applicable) <br /> A. <br /> V New System D Replacemrnt System ❑ Treamrent/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> rIVV. a of POWTS stem/Com onenVDevice: Check all that a 1 <br /> irl Non-Pressurized In-Gromd 0 Pressurized In-Ground O At-Grade D Mound>2A in.of suitablesoil 0 Mound<y{iv.ofsuihble soil <br /> 0 Holding Tank 0 Other Diepenal Component(explain) D Prictmatmat Device(explain) <br /> V.Disparsalffmatinent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Disperaal Ares Required(st) Dupenal Area Proposed(et) System Elevation <br /> r �i00 <br /> �/vrlJ <br /> VL Tank Wo Capacity in Total #of Manufacture <br /> Gallons Gallons Units C) <br /> New Teks K'aning Tarilo y u < m <br /> Septic or Holding Tank lec 0 <br /> Dosing Chamber <br /> VII.Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R,c% /iia k/n s aalSSS/ lis-9a5G — y /S'7 <br /> Plumber's Address(Strep,City,State,Zip Code) <br /> 7 7'6 ❑ ?Y,y Lti G 1,2 X 'e L 2-- Sy 8'9 3 <br /> V111.County/Department Use Only <br /> Approved 1 ❑Disapproved Permit Fee Date <br /> Issued Issuing Ag r <br /> 0 Owner Given Reason for Denial <br /> M Conditions of Approval/Reasorn for Disapproval <br /> Attach to complete plarof n,the system and mbma tothe County ordy as paper rot has then 8 errs x 11 halm in Are <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />