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commereemi.gov Safety and Buildings Division County <br /> ` q 201 W.Washington Ave.,P.O.Box 7162 µYn,e# <br /> i sco n s i n Madison.WI 53707-7162 Sanitary Permit Nuarbcr(to he filled in by Co <br /> _) <br /> Department of Commerce 5-51211 <br /> Sanitary Permit Application State Traaction N.rQober ` �J1� <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental I/ I'Q.UI� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned 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 1X111 <br /> u uses in accordance With the Privacy Law,s.15.04(1)(m),Slats. s <br /> I. Application Info ation-Please Print All Information 6d CLrcon over 1?d <br /> Property Owner's Name (Cv�3-6 <br /> Parcels 07 0,10-d-W0-/ ?-S- <br /> / r e. 01 49.n � 06007- odlo00 <br /> Property Owner's Mailing Address Property Location <br /> 3 $ 86 /I/euv-Aam L re+ Govt Lot 7 <br /> City,State Zip Code Phone Number /, /, Section o'13 <br /> E of Buildn 1"NN SS1,13 (circle one) <br /> T 110 N; R /6 E or® <br /> IL Type ing((check all that apply) Lot 9 <br /> �lor2 Family Dwelling-Number of Bedrooms 12 <br /> (1 3) Subdivision Name <br /> BI k# <br /> ❑Public/Commercid-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> IrTown of O,c✓</E.n p! <br /> III Type of Permit: (Check only one box on line A. Complete tine B if applicable) 000 - _ _ <br /> A. ❑New System y 9 Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Numeran <br /> bd Datelssued <br /> Before Expiration Owner <br /> IV.Typeof POWTS'.S stem/Com onembDevice: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 14Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVrreatm tArea Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevafion , <br /> 300 — — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New TanksExintaig Tanta <br /> Zl V b ra y <br /> cC v rn � Yn o n h <br /> W 7 C <br /> Septic or Holding Tank 3800 �O✓C / .S/« br- <br /> 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)'', Plumber's Signature MP/MPRS Number Business Phone Number <br /> /�/G �� o /c,.,s / <br /> Plumber's Address(Street,City,Sl a Zip Code) <br /> 7 70 a w Y We4ar`-ori G>T S rfB 9 } <br /> VIII. our /De asoment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued In in Signature <br /> S ` <br /> ❑ Owner Given Reason For Denial 3 7.7 7 r7/ �W.lI <br /> W.Conditions of Approval/Reasons for Disapproval <br /> sure: 461"3 Tav k Qevw«t ic, 6o Se 5-wvc4(ed by a s&v. dv �0 .;t Aw hu A.-N. <br /> I. G. p Sot l 4&r6v'^ Cell, $a(uecf re 51i4e ?IdH Ail/waf• ( � <br /> Attach to complete plans for the system and submit to the County only on paper not leu than 812 z 11 inches In size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />