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commereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Nr^ _-- <br /> ' yfiseonsin Madison,W153707-7162 Sanitarry'Permit Numb (to be filled in by Co.) <br /> Department of Commome _ .7 Z I 074— <br /> State <br /> 4_ <br /> State Transaction Num cr <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this from to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(ifdi rentthanmaiImgaddress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 m),Stats. <br /> I. A lication Information-Please Print All Information / Parcel N <br /> Property Owner's Name / /_- � L - <br /> e.,.� L� e• l/ (�rJ _ off- i - •,�- G i5-.5�6-oZa�o_ <br /> Property Owner's Mailing Address ArN2 <br /> AL- • - I Property Location <br /> yS G� .✓1 QDE Az Govt.Let pp 33 <br /> City,S[atc Zip Codc B$222 '/., W '/., Sectioncircleonem _ LGLI�OTl _N; R EII.Typeof Building(check all that apply) Stodrviairn Namc <br /> * or 2 Family Dwelling-Number of Bedrooms_ _.--__ _ �I _ 1BW= <br /> ❑PubliclComtncrcial-Dcscribc Usc ___—_—_____.-- ❑ City of---�� ❑ Village of__ __.❑SomeOwned-DcscribcUsc_-____- --- -- ----- �1'ownof_,_//.{ — 1 —U^�. - <br /> QI.Type of Permit: (Check only one box on line A. Complete line B if applicable) -_— _ <br /> A. O#cw System ❑ Replacement System ❑Trcalni[olding Tank Replacement Only ❑Other Modificatio to Existing System(explain) <br /> B. ElPermit Renewal ❑ Permit Revision ❑Change of Plumber El <br /> Transfer to New <br /> List Previous Permit umber-and Issued <br /> Before Expiration Owner— <br /> IV.T e of POWTS S stem q!jm nentlDevice: Check all that a I ------ ----- -- ---- <br /> - - <br /> --- -- PQY)_. _ --- - -.--- - <br /> �.Non-Pressurizcd in-Ground El Pressurized In-Ground ❑ At-Grade ❑ Mound-_24 in.of suitable soil Mound<24 in.a suitable sof <br /> ❑Pretreatment Device(explain)-. <br /> ❑ Holding Tank 11 Other Dispersal Component(explain)__._. __._--- _ --- -- <br /> V.Dis ersal/'f'reatment Area Information: ---- - ------"----- <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(sQ Dispersal Area Proposed put <br /> s[c wa[lon <br /> S f el e' . __ � - 0C 55 - - -- <br /> --- <br /> -- anufacnuer <br /> VI.Tank Info Capacity in Total tl of <br /> Gallons Gallons lhrils U Pu C <br /> pp v P m N <br /> New Tanks F.xlsting Tssks I i y <br /> Scplic nr lleMlxr�fink 00 <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS�sPh shown <br /> on the Numbctache plans.Businss Phone Number <br /> Plumber's Name(Print) Plumber's Signamrc <br /> �is��� <br /> Plumber's Address(Street,City,State,Lip Code) <br /> e-/-J= -_�2--7 <br /> VIII.Count IDe artment Use Only_ - Issuing- - - -- <br /> - -- --1 lsawn� eat nature <br /> ,,,,..,,—� Permit Pec ..Date IssucJ � 6 <br /> INApprovod ❑Disapproved $ - ��frLy 0 <br /> ❑Owner Given Rcason for De _ ZJ - <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plain for the system end submit to rhe County only on paper nor less then 8 lit x 11 inches Ins u <br /> SBD-6398(R.01/07)Valid thru OU09 <br />