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commeree.wi.gov Safety and Buildings Division Coun <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> is c o n s i n Madison,WI 53707-7162 Sanitary Perm�Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application State 1qMrSocllom aC.Drery <br /> In accordance with s.Comm.83:21(2),Wis.Adm.Code,submission of this form to the appropriate government] sit "-o '"`-`^ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stateowned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Priv Law,s.15.04 I m,Stats. 76 7 <br /> 1. Application Information-Please Print All Information <br /> J' <br /> Property Owner's Name Parcel# <br /> �., .4�5 tam ff <br /> �b ar-o2o•2-90-1�••io-S IS 931-aao2o <br /> Property Owner's M ing Address /n) , ,,,, 1 D Property Location <br /> 3 - e e /�v � /v - Govt.Lot •� <br /> Ci ,State Zip Code Phone Number V, y., Section oc <br /> t Re q- - L A) T N; R (circle ons <br /> 1� <br /> II.Type of Building(check all that apply) Lot# Eo W <br /> Or, 2 Family Dwelling-Number of Bedrooms Subdivision Name // / L / <br /> Block# Lk <br /> y/D� <br /> 11 Public/Commercial-Describe Use <br /> ❑City of <br /> �- CSMNunnW 397 11Village of --� <br /> 11 State Owned-Describe Use 117 A <br /> Va310 72 <br /> ^ %Town of � /I- <br /> 111. <br /> t � — <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applimble) <br /> A. ❑New System ❑Replacement System Treatment/Holding Tank Replacemrnt Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner - A6590 00/47) (o//8/b2 <br /> IV.Type of POWTS S steadCom onent/Device: Check all that apply) <br /> 0 aNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 is of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpcisf) Dispersal Area Required(sf) Dispersal Area Proposed(d) System Elevation <br /> VI.Tank Info Capacity t Total #of Manufacturer <br /> Gallons Gallons Units 3y 0 c <br /> New Tanks <br /> Existing Tanks w o B a <br /> �U N � <br /> Septic or Holding Tank <br /> Dosing Chamber 66, <br /> 16, <br /> (aJ <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatre MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> k <br /> .CDIIIe%artment UseS Only <br /> Approved <br /> =70 Disapproved <br /> Permit Fee Dale Issued C Issuin ignatre <br /> ❑Owner Given Reason for Denial s 325 /74005 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> soil Ra01� as r 3125 1 Meehan loamy Sanofi Mjocoer� Yo : 544 F.- l meo(f i Sar%s, <br /> 5VSfsaw tf rasidf/C< of6 bate * S/epe, is ,a/drdhfa-.r•4464alt S0113- <br /> Attach to complete plana for the system and submit to the County only on paper not less than Sin x 11 inches in sire <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />