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Comm <br /> eree.W"gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> �j fi sero n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Departmem of Commerce 53Z / 75 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm Code,submission of this from to the appropriate governmental ryC -401 e o <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS me Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary n Q <br /> purposes in accordance with the PrivacyLaw,a.15.04 1 m,Slats. /f' '•Ot, r <br /> I. Application Inforination-Please Print All Infonoati <br /> Property Owner's Name Parcel# <br /> �6ljcrt Oe! L(�)- 3 03 & <br /> Property Owner's Mailing Address - Property Location <br /> olS�fb�f Ge lad. FF Govt.Lot 4 <br /> City,State Zip Code Phone Number i Y., Y, Section 141 <br /> w eb,sIer wr �5'4�Sr3 (circle one} <br /> IL Type of Building(check allthat apply) A Lot# T _N; R../Z E oR5(.) <br /> 011 or 2 Family Dwelling-Number ofBedrooma I' L Subdivision Name <br /> Block# <br /> ❑Pubhe/Commercial-Desmbe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V0t. ,7 [VTowo of u n t e M <br /> IIL Type of Permit: (Check only one box on Une A. Complete line B if applicable) -C) <br /> A. ❑ New System TROPlacemem System Treatrumt/HoWing Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑ 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 stem/Com onersdDevice: Check all that apply) <br /> Nan-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Gmh ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Disposal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersalfrecatmentArea Information: <br /> Design Flow(gpd) Deign Soil Application Rzte(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 300 , ar 1 bee I 600 <br /> VL Tank Info Capacity in Total #of Mmmfactur r <br /> Galloon Gallon Unit <br /> New Tanks Existing Tanks u C <br /> tz U vi euro <br /> Septic or Holding Tank 7.$`O Lv/seer X <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb"'.Signature WINIPRS Number Business Phone Number <br /> 12 A-- I'7m BIAS iii-s!/ T/ o�2S8s'/ �S�6G- yis7 <br /> Plumber's Address(S City,Stare,Zip Code) <br /> 7 ;7(,o 3S W ebe�`{r t�1J� S�tSg 7 <br /> VUL Court /De artnent Use Only <br /> Approved ❑Disapproved Permit Fee Dafe leaved luuing igaatmo <br /> S 3.ZJ'°�' 3 4� , r <br /> ❑ Owner Gives RessonforDmial <br /> IX.Conditions of Approval/Reesons for Disapproval <br /> Attach to complete plans fords system and submit to the County only on paper not km[Inn 8 I a 11 Inch.in at. <br /> SBD-6398(R.01/07)Valid than 01/09 <br />