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eommeree.wi.gov Safety and Buildings Division County 'L <br /> 201 i W.Washington Ave.,P.O.Box 7162 13LA r' n'l i seo n s i n Madison.WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce C n <br /> Sanitary Permit Application Stat eT aactian Nu r <br /> Int accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govcmmental l./'e kvle6t/ <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 used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. d <br /> L Application Information—Please Print AB Information <br /> Property Owner's Name .{"�'- Parcel# 67 dl.. A 40 /S dd ♦ /.f <br /> herr /3aarS 3 7OS— 0/6 000 <br /> Property Owner's fling Address Property Location <br /> .70 - i71•11 Apc N. <br /> Govt Lot <br /> City,Stam Zip Code Phone Number <br /> Sf P4-1 /1'I Al '/., Y., Section <br /> S. d <br /> .5-SD�� `sr-a b9 , 9037 (circle one) <br /> Type B(check all that <br /> IL T of Buddin apply) Lot# T /!O N; R /S E cr& <br /> PP Y) <br /> a 1 or 2 Family Dwelling—Number of Bedrooms 3— Subdivision Name <br /> ❑PubEdCommercial—Describe Use Block# H �/PdrU fij t <br /> ❑City of <br /> El State Owned—Describe Use CSM Number ❑l village of <br /> 19'Town of Jackto H <br /> III.Type of Permit: (Check only one box on line A. Complete Iine B if applicable) — a S-D <br /> A. PF News stem <br /> y 11 Replacement System ❑ TreafinenUHolding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS stem/Com onent(Device: Check all that apply) <br /> #Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank 110th"Dispersal Component(explain) 11 Pretreat meet Device(explain) <br /> V.Dis ersaV7'reatment Area biformation: <br /> Design Plow(gpd) Design Soil Application Rate(gpdst) Dispersal Arca Required(st) Dapersal Area Proposed(sf) System Elevation <br /> 3a o . 7 ZqVOA( I �/3ot 9a• o <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallom Unita -1 <br /> New Tanta -fang Tks mrc <br /> xisv c �' m <br /> U C2, <br /> Septic er Holding Tank i�a� pas <br /> Dosing Chamber O s��lstw /Y <br /> VII.Respontibility Statement-1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 fl 3S tai 6s`�� Gv� 54853 <br /> VIIL Cow /De artment Use Ont <br /> Approved ❑Disapproved Permit Feee/ Date Issued Issuing Ag `mre <br /> 11Owner Given Reason for Denial yZ,5t,rj7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atmch m complete plana for are syatem and submit m the County mty m paper mt Int flan 81rs z 11 Inches hi size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />