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ON COMPUTER/SCANNED <br /> commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 /-� <br /> iseo n s i n Madison,Wl 53707--7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> S.21 d Z <br /> Sanitary Permit Application State'rransaclion Number f <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <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 Clay be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> L Application Information—Please Print All Information �)A)CaW t <br /> Property Owner's Name Parcel# <br /> rr A , ;1?o -as-0966 <br /> Properly Owner's Mailinj Address Property Location <br /> 36-0 c I &-I,/ ��r , <br /> Govl.Lot <br /> City.State 7.ip CroJe Phone h % <br /> ,U a �J — . .. Section ) <br /> 5 ��� l�jJ( <br /> / 37 r/- /q-7 cache one) <br /> 1i o� <br /> II.'Type of Bu ing(check all that apply) Lot# [ N; R- Ag _ <br /> JK or 2 Family Dwelling-Number of Bedrooms %� q Subdivision Name <br /> .ol / <br /> .,c t'.a L <br /> -�..-- — _ <br /> El Block lr 1'ublic/Commercial-Describe Use ^ <br /> 11 City of <br /> ❑State(honed Describe Use -/— CShI Number ❑ Village of <br /> 9 ban of <br /> III.'Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. YAlew System <br /> y ❑Replacement System ❑ '1'reatmcnUElolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> 13• ❑Permit Renewal ❑Permit Revision ❑ Change of plumber ❑Pcrmit'1'ransfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1V.Type of POWTS System/Component/Device: Check all that apply) <br /> �4on-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound >24 in.of suitable soil ❑ Mound c 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(gpdsf) Dispersal Area Required(st) DLwperrssal Area Proposed(sf) System Elevation <br /> 20 <br /> VL Tank Info Capacity in 'total #of Manufacturer <br /> Gallons Gallons Units o $ <br /> New Tanks Existing Tanks w [ «°. u v y <br /> C p <br /> �tU in wC) a <br /> Septic or IkiIJivaTank o 0 07eoo �21 <br /> Dosing Chamber /'— <br /> VI1. Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumb 's Signature MPIMPRS Number Business Phone Number <br /> Zz7e< <br /> Plumber's Address(Street,City,State,Zip Code) <br /> eN :r-7 8 <br /> VI II County/lle artn►ent Use Only <br /> 4pproveJ ❑ Disapproved Permit hee llatc Issued Issuin Signature <br /> s �(yO'� 15 Mod/`Cb <br /> ❑Owner Givers Reason for Denial <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 8 1R z 11 Inches in size <br /> SBD-6398(R.01/07)Valid thru O1i09 <br />