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cornmereeml.gov Safety and Buildings Division County �y <br /> 201 W.Washington Ave.,P.O.Box 7162 Bu/h 2—G 1 <br /> jf i sero n s i n Madison,WI 53707-7162 Sanitary Permit Number(tu be filled in by Co.) <br /> oapm I. fft of Commerce 521 08� <br /> Sanitary Permit Application State TransactionNumberW <br /> In accordance with a.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 diftimay than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1 m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name �./. pan-'# 03(o y¢ 23 026oe <br /> Lar. ' /i{/r✓ l Etaev 0703&JYof7d35-oolotdao0 <br /> Property Owner's Mailing Address Property Location <br /> OS S. c-/- SY- Govt.Lot Z <br /> City,State Zip Code Phone Number v, Y,, Section ;3 <br /> �JJ (cycle ony, <br /> DG B✓ 'L (,✓Z J' //S T 4W N; R /7 E'..Ct'he <br /> IL Type of Building(check all that apply) Lot# <br /> 11l or 2 Family DweBmg-Number of Bedrooms Subdivision Name <br /> Block#111 <br /> ❑PubliclCommereed-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Volv 15j Town of UM e2 <br /> III.Type of Permit: (Check only one,box on Ihhe A. Complete line B if applicable) <br /> A, ❑New System Replacement System ❑TreatmmubHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Preview Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S tem/Com ent/Device: Check all that apply) <br /> kNon-Premm¢ed In-Ground ❑pressurized In-Ground ❑At-Grade ❑Mound>24 is of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑OtherDispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersalfrmatment Ara Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required(tat) Dispersal Area Proposed(at) System Elevation <br /> i/so . -� Gars 6y� 9;•a 9v.a <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o , <br /> New Tendo Existing Tanks $ sks <br /> m <br /> m m y is C7 iL <br /> Septic or Holding Tank /000 hep p <br /> Dosing Qsmber Geo boo <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plurals"'.Name(Print) Plumber' <br /> 'ss Signature// ,�/ MP/MPRS Number Business Phone Number <br /> //i/O /LtnS /2'-cs'+-r-r-d // �S SSI 7/S=�/o C�-C//5-'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing lure <br /> S 3%) z3T <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Ress ms for Disappmval <br /> Attach to complete plasm for the system and submit Wthe Cosmly only on paper mot Iss Woo 8 in a 11 inches In abs <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />