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commerce.wl.gov Safety and Buildings Division County0 t �} <br /> 201 W.Washington Ave.,P.O.Box 7162 S (A,L/—G lot <br /> 'S c O n L+i n Madison,WI 53707-7162 Sanitary�rmit Number(to be filled in by Co.) <br /> Department of Commerce b a W <br /> Sanitary Permit Application State Transaction Number I 1 1 <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) �C l <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Z o6Y 3 �4 X-r w paC� 0�, <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> bCL .0 �.�� 03(1- /SLi -08 -ad0 <br /> Property Owner's Mailing Address Property Location <br /> 50 f J% cS-t, /V Govt.Lot Y*s- <br /> City,State Zip Code Phone Number /4, '/., Section Z <br /> IVQ 1�.N� 4�1 Ar .1 S c3 Y ? 9cs 2, -C�S. - d YV i. (circle one <br /> ►I J r J T 37 N; R�Ec� <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms `Z Subdivision Name <br /> Block# CS/" V. I Q 9/ <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ra Town—of A-R <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Re lacement System ❑Treatment/Holdin Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> Y P Y g P Y g Y ( P ) <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 ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ly Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal AVsrea Required(so Dispersal Area Proposed(sf) System Elevation <br /> 06 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o ,�, o <br /> New Tanks Existing Tanks A r. lu 2 <br /> a U in y w C7 <br /> Septic or olding T k `L Zi�4G Z <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> lumber's Name(Pnn) Plumber's Signature Number Business Phone Number <br /> QC 14E. wIj�'A,,S 12- 1-2-87Z— ��Z 'LSlLI <br /> lumb 's Address(Street,City,State,Zip Code) <br /> Y101.Coun /De artment Use Only <br /> Permit Fee Date Issued IssuingAgent Signature <br /> Approved 11 Disapproved $�� ,�„ f <br /> ❑Owner Given Reason for Denial ' U u 5-'15-0 / / I(j��/✓� <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 V2 x 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />