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tcommerceml.gov Safety and Buildings Division County <br /> a a 201 W.Washington Ave.,P.O.Box 7162 ,Qy�N <br /> isconsin Madison,WI 53707-7162 Sani ermitNumber(to befilledinbyCo.) <br /> Department of Commerce - 54 p 4-79-7 A <br /> Sanitary Permit Application State nsaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental U K eUJ <br /> unit is required prior to obtaining a sanitary permit Note: Application fomes for state-owned POW IS are Project Address(if different tha mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> oses in accordance with the Privacy Law,s.15.04 I m,Stats. �M9 <br /> e_ _ ��// p n a <br /> I. A ucadon Information-Please Print All Information /-T/16 Ulborn <br /> Properly Owner's Name Parcel# <br /> c y coW 07 -oho-A -3 - - - <br /> Property Owner's <br /> Mailing Address Property Location p <br /> a �! Cv0/)7 Govt.Lot <br /> City,State//�1 C/�/ / ' '7�" Zip�C/o�de�+(/ Phone Number n&1 � Section <br /> r/T S�f'� �-f' 5T !b (circle one <br /> It.T yp eofBuilding(ch all that apply) Lot# � <br /> T _3 N; R _Eor 'b <br /> yrrrrr�����aaaat� � <br /> / 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block p `— <br /> ❑Public/Commercial-Describe Use <br /> Cl City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> )�rIown of G �/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. <br /> ❑New System Ip-Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <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 S stem/Com onent/Device: Check all that apply) <br /> YqWo Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable 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 /> 7 G Y3 Asa <br /> VI.Tank Info Capacity in Total p of Manufacturer <br /> Gallons Gallons Units v <br /> jNcwanks Ext istin Tanks „'^. V Ovi Septic or HoddvxTankD _ <br /> Dosing Chambers v �� <br /> aq <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Priv Plumber's Signature MP/MPRS Number Business Phone Number <br /> fr �, S�d��2 <br /> / 3X69y9-�Z96 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Q oX -5-/Y S>/- e .�J /,() T S�/k,�',Z <br /> VIII. <br /> County/Department Use Only <br /> Approved Disapproved Permit Fee Datee{Issued 1_I issuingA Si mre <br /> ❑Owner Given Reason for Denial S 325--0 D <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to w.plate plans for the system and s malt to the County only en paper not I.,than B ld x I r Inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />