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ON COMPUTER/SCANNED <br /> commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 r3u r 11 f <br /> i seo n s i n Madison'Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> nepertmerit of Commerce x"3.2. 10 7 <br /> Sanitary Permit Application State Transaction Number Ji <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental C4 <br /> unit is required prior to obtaining s 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 provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1 m),Stals. Cll d b /nab <br /> I. AppBeation Information-Please Print All Information <br /> Property Owner's Name � Parcel lF <br /> &-evtr) Iflavls n o3d .- S3-35- - 08r000 <br /> Property Owner's Malting Address Property Location <br /> ,� d goat 2-n de-p rt)dee i4 C GwcLot /e <br /> City,State Zip Code Phone Number <br /> Yy Yy Section 3S <br /> L,akv ; !l2 <br /> yyr Al S`S6 [/ H (circle one <br /> H.Type of Building(check allthat apply) Lot q 6,,+-. T z// N; R 1G E o <br /> y:I or 2 Family Dwelling-Number of Bedroom (p Subdivision Name <br /> Block q <br /> ❑Public/Commeroial-Describe Use D City of <br /> ❑Sate Owned-Describe Use CSMNumber ❑Village of <br /> Dec 3,f 0 8 71�- .®'Town of _S Gw i s.r <br /> Ill.Type of Permit: (Check only case boa on line A. Complete tine B it applicable) o _ 6 _ _ - - _ _ <br /> A D New System .q Replac®rent System ❑Treatment/Holding Tank Replacement Only ❑Met Modification to Existing System(explain) <br /> B. ❑Permit Renewal D Permit Revision Permit Previous,Permit Number and Date Issued <br /> ❑Change of Plumber 11 Permit Transfer to New <br /> Before Expiration owner <br /> � <br /> IV.`-T of POWTS S stem/Com wient/Device: Check all that apply) <br /> &N--Pressurized In-Ground D Pressurized le-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in of suitable soil <br /> O Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V. aVTreahrtatt Area Wormsd <br /> Design Flow(gpd) Design Sod Application Ratc(gpdsf) Dispersal Area Required(at) Disoen'1 Area Pmooaed(sf) System Elevation <br /> 4 S`o -7 (o Z/ 3 6si. 97 DO <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Ganom Unita ,r <br /> New Tanks Hxieting Tanks <br /> a21 <br /> m m rn R.s r7 ZL <br /> Septic or Holding Tank X00 7-1-0 /J�rQ 9- WGP X <br /> Dosing Chamber <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans <br /> Plumber's Name(Print) Plumber's ASiparturt; MP/MPRS Number Business Phone Number <br /> R/ le � le/nom /G�zcd/ l �dSBS/ 7isSbb-�1�s-> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776 � V <br /> VII Court /De artotent Use 0nl <br /> Appreved ❑DiS <br /> sapproved Permit Fee Date Issued �t Issuing rgnatune <br /> ❑Owner Given Reason forDwul r� "a <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to mmpleh plans for the systeu and subsk to the Counly only an paper rot less thm 8 in 111 aebes in aim <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />