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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 04#1 ile <br /> tiscons i n Madison.WI 53707-7162 Sanitary Pit Number(to be filled in by Co) <br /> Department of Commerce -570,52-3 ( \) <br /> Sanitary Permit Application State Transaction <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �>.T(f FEU i ,,) r <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Addms(if different than mailing address) ^h\— <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary r1 <br /> li!Hposcs in accordance with the Privacy Law,a.15. 1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#07 o jej J 4/ I <br /> ,)IM 'RI:cep( sad m//..a <br /> Property Owne's Mailing Address Property Location <br /> ys 7q Lr.asJM^" Or Govt Lot 143 <br /> City,State Zip Code Phone Number <br /> '/., Section � L <br /> D41 h tau o 4/,j" .S�830 T� N; R /1`cec1E one) <br /> IL Type of Building(check all that apply) Lot# <br /> 0409 <br /> A 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Deeaibe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number r❑I Village of <br /> ✓. 7 pal a/ Y] Town of xd,✓ff I <br /> I IL Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A. <br /> ❑New System ,[ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑ <br /> B. ❑Peami[Renewal Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWTS S stem/Com ent/Device: Check all that apply) <br /> R Non-Pressurized In-Ground ❑Pressurized In-Gmuod ❑ At-Cmde ❑Mound>24 in,of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. aVT)atment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) tDispmala Proposed(at) System Elevation <br /> '1115 7'(.0VI.Tank Info Capacity m Total #of erGallo= Gallons Units °, UNew Tanks Existing Tatars w le� U 'vr m SepticwBe=ing rank /A a o /aAsu I! <br /> Dosing Clamber <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> MP/MFRS Number Business Phone Number <br /> RICA'- o /c/nJ /Ge.ac.�r �� arslSBS/ 74r- S46 Vet-> <br /> Humber's Address(Street,City,State,Zip Code) <br /> 7760 Nom- 3S df/ebaf <br /> VIII.Count /De artnamt Use Old <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing tune <br /> S � <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovaUReasoan for Disapproval <br /> Aaarh to atmplefe Alam for the system sad suhea m the Couray wdy m paper not less than 8I x 11 Inches in size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />