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COmmerce.Wl.gov Safety and Buildings Division Court <br /> a 201 W.Washington Ave.,P.O.Box 7162 t.r h-f tf <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce Y / 8 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental (1.76y\ #Qe VIQa <br /> unit is required prior to obtaining a sanitary permit Note: Application fors 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 /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stints. NIJ <br /> 1. Application Information-Please Print All Information - r <br /> Property Owner's Name Parc-l# &T-0.t 8•A•V01/1.6_S"'I.fe-ea 0- <br /> De-6 RU /A I ef' 0 (/9000 (04$1 GW <br /> Property Ownma's Mailing Address Property Location <br /> 3Jk(90 !! ,$ e" GNKYn <br /> Go"t.Lo[ <br /> City,State Zip Cade Phone Number /, %, Section 7 <br /> �/1/2c.ty f"Y✓ u�� •TyBI� T 40 N; R 1y(circlEcone <br /> .,IOL Type of Building(check all that apply) 3 Lot# q <br /> &I or 2 Family Dwelling-Number of Bedrooms 37 Subdivision Name <br /> Block# rndO A 4116E <br /> ElPublic/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑Village of <br /> 9 Town of .SGB <br /> III.Type of Permit: (Check only oro box on line A. Complete line B if applicable) <br /> A. ❑ y New System System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Perit Revision ❑ Change of Plumber List Previous Peril Number and Date Issued <br /> ang ❑Peri[Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> 4 Non-Pressurized In-Ground ❑Pressurized br-Ground ❑ Al-Grade ❑Mound>24 in.of suitable soil 11Mound<24 in,of suitable soil <br /> ElHolding Tank ElOther Dispersal Component(explain) El Pretreatment Device(explain) <br /> V.Di ersal/1'reatmcut Area Information: - <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 7 6vJ I 6yd 9e.a g/. o <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallom Gallons Units 3 c o <br /> New Tanks Bxuting Tadcs w U$ b + <br /> U in m h iW C7 GL <br /> Septic or Holding Talc <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phene Number <br /> 1Z.c% y s FO drecsrBs-, 7•x866- y�s � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 /-/— ? 3s U/e�s�ti wr SziBS� <br /> VII Conn /De artment Use Od <br /> Approved ❑Disapproved Permit Fee pyJ Date Issued f^ Isau' A ISignriure <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atbch to compete plana for the system and submit totbe CouNy only on pacer not less than 8 in x 11 hahes In alae <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />