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ON COMPUTER/SCANNED <br /> commerceml.gov Safety and Buildings Division CountyI� <br /> 201 W.Washington Ave.,P.O.Box 7162 U u rn 87q <br /> s c o n s i n Madison,WI 5 3707-7 1 62 Sanitary Permit Number(to be <br /> ttiepartment filled in by Co.)of Commerce 5 <br /> Sanitary Permit Application State Tra action Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental v A(/1&') <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 <br /> oses in accordance with the Privacy Law,s.15.04(1)(m),Stats. ?Q�sa <br /> I. A lication Information-Please Print All Information /�(J e, <br /> Property Owner's Name /// Parcel# <br /> Jos11 fe ��✓S C�' 07-0/0-2-3d-19-&-2-02 OW-011pp <br /> Property Owner's Mailing Address Property Location aq 0 <br /> ) Lf-?H) f if V e Nelson jlcl G c <br /> City,State Zip Code Phone Number t Ir,l /,, OW , <br /> /4, Section lb <br /> -S•N S'f 0 7/S- 5d 9- 0 6 8s- (circle one) <br /> IL Type of Building(check all that apply) ) Lot# T 3 8 N; R E 0 <br /> 1 or 2 Family Dwelling-Number of Bedrooms 7` Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> El State Number ❑Village of State Owned-Describe Use de �/.-y�)&� 33 <br /> V Town of Gran�-J bu r s <br /> w 4� <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' Or New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound 124 in of suitable soil ❑ Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) I Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3 0D S` 6e0 600 9,0•r <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units V o'$ o <br /> New Tanks Existing Tanks v y U A <br /> Septic or Holding Tank Gioo Sd0 I Ka tnJ <br /> Dosing Chamber O <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> Rle - lya k/hs / � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 7 &O t,r.y 33S <br /> V111L Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent re <br /> ❑Owner Given Reason for Denial § ���� I 13 0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 4- 4r-&3 V 4006k) CSAt t'e�G�tnS. <br /> Attach to complete plans for the system and submit to the County only on paper Dot less than 8 1R x 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />