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COmmerCe.Wl.gOv Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 �ur n'e 7� <br /> i se o n s i n Madison WI 53707-7162 Sanitary Pemhit Number(to be filled in by Co.) <br /> Departmem of Commerce 2 <br /> Sanitary Permit Application State Transaction Number <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 may be used for secondary <br /> w ses in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information 8437 5eiAer i-ed ;\ \ <br /> Property Owner's Name <br /> Mark SR tN pr t 11 Ol.l - 40 7- rQ - 7D / <br /> Property Owners Mailing Address property Location <br /> / 6d0 /�ilero. C <br /> Govt.Lot JL_ <br /> City,Smte Zip Code Phone Number +/4, y,, Section 7 <br /> -,! /1✓Cr li r'e v'Cly Li'F! SS077 T NO N; R_ 1,57- E- <br /> It.Type of Building(check that apply) Lot# <br /> ® I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> D Public/Commercial-Describe Use _yam <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number DVillage ofIf T_t/C sok, <br /> ✓O( )� 12(. Town of a/G <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. D New System D Replacement System ❑Trealment/Holdin Replacement Only g Tank ep yOther Modification to Existing System(explain) <br /> rrl e✓e a n /< <br /> B. D Pemtit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New List Previous Permit Numbcr and Dale Issued <br /> Before Expiration Owner. <br /> IV.Type of POWTS S stem/Com onemb Device: Check all that apply) <br /> D Non-Pressurized In-Ground D pressurized In-Ground D Al-Grade D Mound>24 in.of suitable soil D Mound a 24 in.ofimitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Arca Proposed(st) System Elevation <br /> V1.Tank hdo Capacity in Totalq of Manufacturer <br /> Gallons Gallons Units o o $ v <br /> New Tanks ac <br /> Erzisting Tanks C) .p <br /> a 9 $ b <br /> ctU i%+ � Ze wc7 a <br /> Seplie or Holding Tads <br /> /0a0 /OBO <br /> Dosing Chamber <br /> bea 6ao <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation orthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /�/c/C f�® /u s / -,o SBS/ lis- f66- Ws-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 76 e /tet, p 3S W-e6s7 e� GvrSy j3 <br /> VIIL Coun /De t rtment Use Only <br /> Approved D Disapproved Parnit Fee D�atelssued p Issuing nature <br /> D Owner Given 7 <br /> Reason for Denial S ado ( O�i 2>5 <br /> LY.Conditions of Approvah Reasons for Disapproval <br /> Ndrh to complete plans for the-Yate-aM submit to the Courdy-dy on paper rat ler than a in a 111rch.to size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />