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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 to Is P <br /> tisconsin Madison.Wl 53707-7162 Sanitary Permit Number(to be Filled in by Co.) <br /> Department of Commerce -5 /O- a c' <br /> Sanitary Permit Application Stale Tran--chon Nber <br /> Comma.In accordance with s.Com .83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 119,353815 <br /> p 9353 Qumv5 \JV <br /> unit is required prior to obtaining a sanitary permit Note: Application Forms for siaterowned POWTS are ProjnectQAddress(ifdifferentthanmailingaddress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary l l <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 'aid I 1 <br /> I. Applimnon Information-Please Print All Information <br /> Propertj Owner's Name Parcel#p�.p16.2•`/0/'r'7J3•S OSYa7$'o/L� <br /> Chcr I l�avl er) c) #3 87� o12y ak Dat bl0 <br /> Property Owner's Matting Address Property Location <br /> NGi3 Cc�?ctr Gia Jew. Govt.Lot .3 <br /> City,State Zip Code Phone Number Y. A A <br /> Sf / ,/ , Section <br /> • lip e41.3 It a F m Al SSq�b (circle one) <br /> �IILL(Type of Building(check all that apply) Lot# T N; R /tea _E or® <br /> H3.1 or 2 Family Dwelling-Number of Bedrooms 2, Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> 0 State Owned-Describe Use CSM Numb" ❑ village of <br /> V. I& NTown of 9C•79— <br /> IDL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. y <br /> pt New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑PermilRrnewal ❑Perm@Revision ❑ChangeofPlumber ❑Permit Transferto New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWTS Sys tem/Com onent/Device: Check all that apply) <br /> ❑ Non-Presamized In-Ground 0 pressurized In-Ground 0 At-Grade ,0 Mound 124 in.of suitable soil 0 Mound 124 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispera d Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 . 9 3&e 336 qs.s <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallows Gallons Uniu w c <br /> New Tanks Exisfing Tanks gu V 'y <br /> U in m iw A <br /> Sspticor Holding Tank 7�!'•O 7-f'O <br /> DoanB Chamber SQd SOO <br /> VII.Responsibility Statement-I,tM1e undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) plumber's Siignature�/ MP/MFRS Number Business phone Number <br /> 2/GIG /7�0 �CIrS IGuln..clL /Y ��S�S I 7/�=FfGG'11�5 T <br /> Plumber's Address(Street,City,State,Zip Code) <br /> o 7 , 6 0 3 <br /> VII Cour /De artment Use Onl <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing cut 'gnature <br /> 5 /�� ^ <br /> 0 Owner Given Reason for Denial 375,16 f'Pty.20 20)1 <br /> IX.Conditions of Apprwal/Reasons for Disapproval <br /> Attach m complete plans for the system and submit to the County only on poem not less than,a 1a 1111 M size <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />