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tFommerceml.gov Safety and Buildings Division County 7 <br /> 201 W.Washington Ave.,P.O.Box 7162 ,(7 u r n @� <br /> til consin Madison, filed W153707-7162 Sanitary Permit Number(to be ed in by Co.) <br /> Dep"rnard of c"nrromme 53 22 <br /> Sanitary Permit Application State Transaction Numynber <br /> In accordance with .Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate govemmeMal C/W�Y l,e'Ul <br /> unit is required or m obtaining a sanitary permit Note: Application forma for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the1 oPartment of Commerce. Personal information you provide may be used for secondary LJ <br /> Purposes in MCe with the Privacy Law,a.15. 1 m,Stan. <br /> I. Application IfOR7111101102-Please Print All Information '19 g;Lr ee 41 <br /> A'oPMY Owner's t me ^ Parcel# W <br /> P4-' IG/< G' � <br /> Property Owner's Ealing Address 0.48-yL tion - <br /> 8/( I"R K /`�/L.te yr t✓a ProPed3'Lncation <br /> Govt.Lot s <br /> City,StateZip Code Phone Number <br /> yh Y4 section <br /> /l�t:rtdefa /j/j fY)A/ Ste$`//S (circle oro <br /> IL Type of Build (chink all dost apply) p Lot a�j T ri'O _N; R�_E o <br /> IR I or 2Family elling-Number of Bedrooms J Os Subdivision Na me <br /> Block# <br /> ❑PublieJCommerc -Describe Use <br /> ❑City of <br /> ❑State Owned-D,mcfibe Use CSM Number ❑Village of <br /> ]j Z R 1 /Q -7,-0-7'74of W Town of -7,-0-7'74-7 <br /> ITL Type Pe on <br /> 't: (Check only one box on lime A. Complete line B if appliable))r OQ _ o 'a� - <br /> A ❑New S s <br /> y �Replacemrnt System ❑Treatmrnf/Holding Tank Replaeemrnt Only ❑Other Modification m Existing System(explain) <br /> B. ❑Penmit R at ❑permit Revision ❑ Change of Plumber ❑Permit Transfer m New List Provioua Permit Number and Date hsued <br /> 13eforo Exp' tion Owner <br /> �IVr.Type of PO 5 S tem/Com mVDevke: Check aU that apply) <br /> .C1 Nen-Pnmeurized -Ground ❑Pressurized lo-Groond ❑M-Grsde ❑Mound>24 in.of suitable soil ❑ Mound<24 inof suitable soil <br /> ❑Holding Tank Other Di pwsal Component(explain) ❑Preheatmwt Device(explain) <br /> V.Dislimalffire Invent Area Wormadon: <br /> Design Flow(gpd) Design Soil Application Rate(gpdef) Dispen l Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 45-0 . 7 6 4f3 b 4 i? 9/• 00 <br /> VL Tank Info Capacity in Total #of Ma nufacfie <br /> GeneralGaRom Unita °' g <br /> New TsJra a _ o <br /> Fvuaurg Tends <br /> n . w icy M <br /> Septic or HQk9j Tank /DOO /000 / .fta w <br /> Dosng Clumher <br /> VIL Respondbid Statement-L the undersigned,assume responsibility for installation of the POWTS shown to the attached plans. <br /> Plumber's Name(Pr' t) Member's Signature 3Wel RS Nrmber Business Phone Number <br /> /?1G/G <br /> Plumber's Address(E rset,City,Sore,Zip code) <br /> d 776 D elW Y 3S It,/ r e L✓S STSs v <br /> VI Cow /Dertment Use Only <br /> Approved ❑ iaapproved Permit Fee <br /> Date Issued Issuing rgnature <br /> ❑ erGiven Remonfor Denial a✓^v � /2 b2Al <br /> IX.Cwdidons oI pptovaUReasom For Disapproval <br /> Attach to eosplete plan for the syafes ad mbmb to the Com <br /> sty only on paper sot has Wm B lrs:ll inters in site <br /> SBD-6398(T01/0id thru 01/09 <br />