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Cornmeroe.Wi.goV Safety and Buildings Division County / <br /> 201 W. Washington Ave., P.O. Box 7162 4Yf1.B f'f <br /> i scons i n Madison, W 1 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce 52/ oo9 <br /> Sanitary Permit Application slate"Transaction Number <br /> Fis <br /> rdance with s.Comm.83.21(2),Wis. Adm.Code,submission of this form to the appropriate governmental —d— Jj <br /> unit 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 he used for secondary <br /> u ores in accordance with the privacy Law,s. 15.040 am),Stats. / f <br /> I. A (0 7 <br /> Application Information-Please Print All Information 0 �- �u I I Tc•.0 <br /> Propem Owner's Name Parcel 4 <br /> G I-,?Ce L��(-tie �, � or,)-o- <br /> Propem Owner's Mailing Address Property Location <br /> o PVra� L�� �✓ Go" Lot <br /> r1or <br /> Zip Code Phone Number <br /> ,(/E 'A._ 'G, .Section <br /> ��( aoI (circleme <br /> f Building(check all that apply) Lot q T �� N; R E or w <br /> mily Dwelling-Number of Bedrooms Subdivision Name <br /> Block q <br /> ❑Public/Commercial-Describe Use <br /> ❑ LJ City of <br /> State Owned- Describe Use CSM Number ❑ Village of <br /> X Town of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> v <br /> ❑ New System Replacement System ❑"Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Chan e of Plumber List Previous Permit Number and Date Issued <br /> B ❑Permit Transfer[n New <br /> Before Expiration Owner <br /> IV.Tv e of POWTS S stem/Com onenUDevice: Check all that apply) <br /> N-Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound 124 inofsuitable soil ❑ Mound 124 inof suitable soil <br /> ❑ Holdmg l ank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)__ <br /> V. Dis ersal/Trestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Pro <br /> Pe , / posed(sf) System Elevation <br /> 010 r7 y2 `4SDq6, So <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units _ c <br /> Ncw Tanksfxisung tanks' 2 b _ <br /> " U u _ <br /> � <br /> i U 7 y <br /> .epnc riding l aril, <br /> Dosing Chamber <br /> V 11. Responsibility Statement- 1,the undersigitu ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pk ber's Signs or MP/MPR.S Number Business Phone Number <br /> Plumber's Address � <br /> treet,,Uty, ,Zip Code) ��� <br /> 1 S� <br /> t <br /> VII Count /De artment Use Only <br /> Appnrvuf ❑ Disappo)Ned Permit 7ee Date Issued Issuin nl Signature <br /> ❑ 610-17 <br /> Owner Given Reason for Denial 3 to8 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Xforch up CionluCtenlmS Tor me,%viternand submit to the(ounry only on paper not Iris than 8 112 x 11 ..rhes in sire <br />