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commerce.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Ott p)f to t1 <br /> - <br /> I seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Departmem of Commerce 59,22� '3 <br /> Sanitary Permit Application State Tranaaction Number <br /> In accordance with s.Comm.53.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. NOW: Application forma for stat"wned POWTS are Project Address(if different than mailing addresa) <br /> submitted m the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1)m,Stan. ��� <br /> L Application information-Please Print An Information 6k') re Z. � e <br /> Property Owner's Name Parcel H <br /> J04 Yl 0t3r/e 00 g. geso - Cel - 300 <br /> Property Owner's Mailing Address Property Location <br /> 7d S' OQ Ic —<4 Govt.Lot <br /> City,State Zip Code Plnne Number <br /> Ann Y., Y., Section I <br /> ,O!O H WS .�/O/b 6io1 /tic//- 7 790 .33 (circle one) <br /> IL Type of Building(check all that N, R that apply) Lot# ! <br /> ®l or 2 Family Dwelling-Number ofBedrooma T)) Subdivision meBlock# S <br /> ❑PublidCommemial-Deepi6e Uae <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Villageof <br /> Town of tet-e)/ <br /> Ill.Type of Permit: (Check only one box on lime A. Complete line B if applicable)0 _ _I _ _ _ <br /> A New System ❑Replaoernmt System ❑Treatment/Holdin <br /> B Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. jKPermit Renewal ❑Penoit Rwision ❑ eofPlumber List Previous Permit Number Date Issued <br /> Clang ❑Permit Tzan,fer to New <br /> Before Expiration Owner 2 / <br /> IV.Tvve of POWTS stem/Cmn mmVDevice: Check all that appl J r0 <br /> Non-Pressurized m-Groond ❑Pressurized In-Ground ❑ At-Grade ❑Momd>24 in.of suitable sod ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explam) ❑Pretreati mt Device(explain) <br /> V.DispenabTireaturen,t Area LhfoamatlM <br /> Design Flow(gpd) Design Soil Application R W gpdsf) Dispersal Arm Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 300 . 7 4,l 9 I y 3d 9 9, (7 <br /> VI.Tank Wo Capacity in Total g of Manufactures <br /> Gallon, Gallon, Unita h s <br /> New Tads geeing Tanks <br /> c <br /> a <br /> Septic or Holding Tads <br /> Dosing Clamber SOQ OQ <br /> VIL Respot b(ipllty Shtement-f,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana <br /> Plum6er's Name(Print) Bomber's Sigoadue MP/MPRS Number Biomass Phone Nomber <br /> /2-.A . Ne,OIf/nJ J .� f/ �lasasl 7/.s 866- y,r> <br /> Plumba'a Address(Street,City,State,Zip Code) <br /> X76 0 W .W- 4VgAs{e-- W7- S1f853 <br /> VIIL Coun /De artimnt Use Ont <br /> Approved ❑Disapproved Permit Fee Date Iseucd Issu'nhg ent Signmue <br /> S <br /> ❑Owner Given Reasonfor Denial O/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Reneu-al of <br /> Attach n complete plan for the syncs and mhsa nth County only an paper ooh les than a 1r x 11 ineha b sic <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />