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eommereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave., P.O.Box 7162 Q' Pan <br /> isco n s i n Madison,WI 53707-7162 Sanitary Permit N e filled in by Co.) <br /> Depertment of Commerce ,5, <br /> Sanitary Permit Application State Transaction I <br /> In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this fun to the appropriate • Ss governmental unit is required prior to obtaining a sanitary permit Note: Application forms for sate-owned Project Address(ihan mailing address)POWTS are submitted to the Department of Commerce Personal information you provide may be used for <br /> seconds ur osesin accordance with the Privac taw,s. 15.04(1)(m),Stats. ) L Q�1. A lication Information -Please Print All Information /+.S /7 /PropeZnOwner's Name Parcel# o7_ _37 ��-a6VW,� A //a ✓e.N � ,�33) 03- - � �oProperty ner's Mailing Address Property Locatioe e �� ovt.Lott ��City,State Zip Code Phone Number .4E! ya ection7g `>�`o ) <br /> T N; <br /> 1I.Type of Building(check all that apply) Lot# <br /> Subdivision Nam <br /> 1 or 2 Family Dwelling-Number of Bedrooms — <br /> Block# <br /> ❑ Public/Commercial-Describe Use_ —_ ❑ City of_ _— <br /> CSM Number ❑ Village of <br /> ❑Slate Owned-Describe Use <br /> -- �Town of Q. <br /> 111. Type of Permit: (Check only one box on fine A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modific ition to Existing System(explain) <br /> List Previous Peit Numberand Date Issued <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New <br /> r <br /> Before Expiration Plumber Owner <br /> I, rype of POWTS System/Component/Device: (Check all that apply) <br /> 11 /y <br /> Non-Pressurized InGround ❑ Pressurized hiGround ❑ At-Grade IlMound> 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil <br /> ❑ Holding Thnk ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) _ <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsD Dispersal Area R quire (sf) Disper. Area,Proposed(sf) System Elevation/O <br /> 97 ,5 <br /> VI.Tank Info Capacity in Total of Manufacturer d 8 <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks o u- 2 0 <br /> U m y h u. C7 d <br /> e tl r};olding Tank 7,5--Q <br /> Dosing Chamber 5,06 r5-0 C) <br /> VII. Responsibility Statement - 1,the undersigned,assume responsibility for installation of the POWTS shown on the all ached plans. <br /> Plumber's Name(Print) PI ber' Sig rare MP/MPRS Number BBuusiness Phone Number <br /> Plumber's A dress Street,City,State,Zip Code) <br /> VIII.County/De <br /> ent Use Only <br /> Permit Fee Date Issued Issuin gen ignature <br /> ❑ Approved $ <br /> Owner Given Reason for Denial <br /> 5v'D I UL ' <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than s la x 11 inches size <br /> SBD-6398(R. 01/07)Valid tbm 01/09 <br />