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commeree.wl.gov Safety and Buildings Division County n <br /> 201 W.Washington Ave.,P.O.Boz 7162 C4 <br /> ifsconsin Madison,W1 53707-7162 Sanitary Permit Number(to be <br /> illedinbyCo.) <br /> Department of Commerce '5-5 /,218 v' <br /> Sanitary Permit Application State Transaction Number - paub M <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <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 pro ' e may be used for dary <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stars. yn <br /> I. Application Information-Please Print All Information /t0 <br /> Property O er's Name y C Parcel t✓ O �� <br /> Property Owner's Mailing AddressA/ Property Location <br /> �f' Govt.Lot <br /> City,State Zip Code Phone Number <br /> Y., Section <br /> ircle one <br /> II.T Type Building T,� N; R�Ea� <br /> �,.,f YP $(c all that apply) Lot# �_, <br /> `911 or 2 Family Dwelling-Number of Bedrooms _.3 _ Subdivision Name <br /> Block k <br /> ❑Public/Commercial-Describe Use <br /> � ❑City of �- <br /> —Number❑State Owned-Describe Use CSM Num0 village of <br /> own of O U-7_o (z <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. 11 _ <br /> New System ❑Replacement System reatment/Hulding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 11 <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 System/Component/Device: Check all that apply) 1/0 01 <br /> —J' J <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitab soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> VI.Tank Info Capacity in Total p of Manufacturer <br /> Gallons Gallons Units o 9 <br /> New Tasks Existig Tanks m c y u � <br /> Septic or Holding Tank <br /> Dosing Chamber Sec <br /> VII.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 MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Court /De artment Use Onl <br /> Approved ❑ Disapproved Permit Fee Date Issued" Issuing Xent gnature <br /> ❑Owner Given Reason for Denial 1 <br /> $ a o <br /> IX.Conditionsq9�(ApprovaUReasons for Disapproval <br /> SdttferY =116 ISSveX co allow fe#Ua a 4->< pf Cu(kOfat S(yre( rk/> k?n� <br /> �v(;e �/tun, iApM�l is lekuirell /natna.c4 as Pf,,,r!>�d.a,e serk'f a Mdt.aaoly'-t�r'e ow-�.r <br /> Attach to complete plans for the system and submit to the County only on paper not has than 9I x I I Inches In size <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />