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ccimmerce.wl.gov Safety and Buildings Division County <br /> 4t201 W.Washington Ave.,P.O.Box 7162 13A n v e7 t <br /> isco n s i n Madison.WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application State Transaction Number Jj <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental '""rlr— <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 need for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> L Application Information-Please Print All Information 36(P9 I-oon 4a �� <br /> Property Owner's Name .//I{ Parcel <br /> /A # <br /> LtMile✓ScG T( 012. N}DI oSot00 <br /> Property Owner's Mailing Address Property Location <br /> 6 '786 4,lene /Qve <br /> Govt Lo[ <br /> City,State Zip Code Phone Number Y, Yy Section <br /> rnvee I'i✓a✓e N tit1 5-.r077 6SI-YS7- / I oe T �0 N, R /Pucleone) <br /> IL Type of Building(check all that apply) Lot 4 E o� <br /> ®1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSM Number El Village of <br /> ®Townof JAG/L,sin <br /> IIL Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A. ❑New System X Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com ent/Device: Check all that apply) <br /> ®Non-Pressurized In-Ground 0 Pressurized In-Ground 0 Al-Grade 0 Mound->24 in,of suitable soil 0 Mound<24 in of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device <br /> (explain) <br /> V.Dis ersalfrreahnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> yso . 7 6A 6 y9 911.3 <br /> VI.Tank Info Capacity in Total #of Manufacturer o <br /> Gallons Gallons Unita pp° o <br /> New Tank. 6zisting Tardy „�yqy. £ u 15 )( m y <br /> S. <br /> Septic a Holding Tank /e O� <br /> /B®O <br /> Do trig Chamber 6 D d &a <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 Phone Number <br /> /c/e-/G <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL Court /De at�hent se Onl <br /> Approved 0 Disapproved Perm2it/Fee DatGGe��Is�ued pp Issuin rgnature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Apprmal/Reasons for Disapproval <br /> Attach to compete plan for the"stem and mbmit tothe County only on paper rat lee than a in x 11 fachea In sin <br /> SBD-6398(R.01/07)Valid than 01/09 <br />