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eommerceml.gov Safety and Buildings Division County p <br /> 20l W.Washington Ave.,P.O.Box 7162 {� r r F 1t- <br /> i seo n s i n Mtlashln WI 53707-7162 Sani Dit u be filled in by Co.) <br /> Departnaerit of <br /> Sanitary Permit Application SbteT ane 'un Number ' `6 <br /> In accordance with s.Comm.83.21(2),Wis.Adra Cade,submission of this form to the appropriate go onausa d �Q W <br /> unit is required prior to obtaining a sanitary permit Note: Application fomrs for state-owned POWTS are Project Addr s(if different than wading address) <br /> submined to the Department of COmmerce. Personal irdbamation you provide may be used for secondary <br /> purposes M accordance with the privacy Law,a.15. 1 m Stab. 76 7 Lex P/a hf�C 0,L A tieation Wormation-Please Print AN Wormation <br /> Propmty Owner's Name <br /> Parcel# <br /> S"ve Chrrsfentcvt Cry.# 3atia8 ad - 9/7/-0(800 <br /> Property Owner's Mailing Address pr pont, hou / <br /> J, 78,( 3 Yep/O«, tie /�e�• GovL Lot Lam/ <br /> City,State Zip Code Phone Number Yy Y., Section ah <br /> W/2aS1-vv WS s4&93 7/s 866-Y8,t 6 (cycle one). <br /> IL Type of Fling(check an that apply) Lot# T y0 ; R 46 E o f(7 <br /> 111 or2FamilyDwelling-Number ofBedmoms 3 Subdivision ams <br /> ❑PubliclCommercul-Describe Use Block# .& 0;11. <br /> O Cityof <br /> ❑State Owoed-Desrn'be Use CSM Number ❑Villageof <br /> P(Town of 04/k/R.a <br /> IIL Type of permit: (Check only este box on tine A. Complete tine B if applimble) <br /> A. New System ❑Replacement System ❑ Treatmunt/HoWin <br /> g Tank Replaoxnent Only ❑Olher Mad fIMtiM to Existing System(explain) <br /> B. Permit Renewal (]Pannit Revision O Change of Plumber ❑Permit Trawler to New Lbt Previous ANunberand Ddchsued <br /> Before Expna im Owner <br /> IV.Type of POWTS 3 tem/Com mt/Device: Check all that a <br /> .K Non-Presurized In-Ground O Preasurved In-Gmund O At-Grade O Mound->24 m of suitable soil O Mound< in.of suitable soil <br /> OHoldng Tank OOther Dispersal Compowa,(eaplaia) O Pretreatment Device(expkin) <br /> V. eryaVTreabnent Area Wwaintion: <br /> Design Flow(gpd) Design Soil Application!!KP" Dupmal Area Required(s0 Dispersal Area Proposed(et) System Elevation <br /> Oro . S— 1700 goo 9d • 6 <br /> VL Tank Wo Capacity so Total 8 of Manufacturer <br /> Gallon, Galbm Unita u o <br /> New Tanksfvunirhg Twdra �� $ <br /> S!+ rn .n k, C7 tsd <br /> Sgta.w Holding Tank /0t90 <br /> EG;--g Chaaber <br /> VII.ReaIn=b(ipri Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the ab ed plan& <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> k&.le ,/ <br /> f1a E.nf /Zc�p,.P r7 �!lsBs/ 7.r f�L6-vis? <br /> Phmrber's Address(Street,city,state,zip Code) <br /> ,x 776 D f/r 3S Lv26s{rte lvZ S`t�9? <br /> VIIL Coun /Department Use Only <br /> Approved O Disapproved Permit Fee Dale sued Ism igrsture <br /> S ^`-� 27 b7 <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasa ns for Disapprovd <br /> Attaeh n cospkte plan sr the syatesand swans tithe County only an paper not has than 8 in x 11 Jwi;;;-I I ilu <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />