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ON COMPUTER/SCANNED <br /> Commercemi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Z <br /> i s c o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 53 Z 23 T <br /> Sanitary Permit Application State <br /> ,Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 165 5/39 <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 C <br /> oses in accordance with the Privacy Law,S.15.04 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Pro7 Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location n <br /> 74, C i Cr3 d'�,C I G� � Govt.Lot <br /> City,State Zip Code Phone Number , <br /> �Q �L ! ��% J ' Section <br /> � j 7 ��ji/V �6 6 3 (circle oje <br /> II.Type of Building(check all that apply) Lot# T �' N; R �6 E o� <br /> Al or 2 Family Dwelling-Number of Bedrooms � � Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> �- ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of /. <br /> Town of 0 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable <br /> A. ANew System 'y 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 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 JX Mound>24 in.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(gpdso Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o a o <br /> New Tanks Existing Tanks c <br /> w U <br /> Septic or Hgldme Tank /0 Q v Lh <br /> ICJ z <br /> Dosing Chamber �w — — <br /> v <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name Print) n Plumber's Signature / MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIJeCounty/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee +'h QDate Issued p Issuing nt ature <br /> ❑Owner Given Reason for Denial $ 375! / 1#0V1 0/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than g 1/2 x I inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />