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COmmerce.wLgoV Safety and Buildings Division County. C_fes, <br /> �1 <br /> 201 WWashington Ave.,P.O.Box 7162 n <br /> ti <br /> s e o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Deportment m Cotrnneros 252- 115 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of,this torn 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 mail ing 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,s. 15.04 I m Stats. <br /> 1. Application Information-Please Print All Information � <br /> Property Owner's Name // o <br /> � £ a mR2K ,6TRL o.L[JOr_FiE Parcels 21Q 3J23 O/2 PID <br /> 4da,'FEAd7- _L-39-/�-Z3-/• 02.Olto-otI <br /> Property Owner's Mailing <br /> gAL../ <br /> Address /� Property Location <br /> /Ses- D..x wme Iamu-- Govt.Lot <br /> City,State 11 Zip Code - Phone Number nfA) y, _nE A Section 23 <br /> 61000 5#S'0j T�3�N: R circleonU� <br /> H.Type of Building(check all that apply) Lot k <br /> �I or 2 Family Dwelling-Number of Bedrooms Z_ Subdivision Name I j <br /> Block N <br /> ❑PublidCommercial-Dt.scribe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ,D Village of <br /> 9 Town of _W_ <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> A <br /> ❑New System a,Replacemen[System ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Chane of Plumber List Previous Permit Number and Date Issued <br /> Change El Transfer m New <br /> Befoie.Expimtion - Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> Nan-Pressurized In-Ground 0 Pressurized In-Ground 0 Al-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in of suitable soil <br /> ❑_Holding Tank D Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 . 7 3Z /FSo > 89.0, 560. 0 ' <br /> \'I.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons - Gallons Units <br /> New Tanks FxistingTW:s - <br /> i <br /> Sryoc or Holding Tank .2_0 1 7.5'0 /070 2 o5Oi Gtr -a)f el$w� .� <br /> Dosing Chamber <br /> VII.Responsibility Statement- t,the undtirsig4ed,ass9ale responsib'r for installation of the POWTS shown on the attached plans. <br /> PhaN;plrYjy.mei.rZ 8t EXCAVATION lit ignelure MP/MP�R,{S pNumbbeer Business Phone Number <br /> N62 sACF' �I I INP ROAD �7/f7 7 <br /> Plum Kt, (g o e) <br /> s s� <br /> �VIII.County apartment se nl <br /> q Approved ❑ Disapproved Permit Fee Date Issued Issuin A ignalure <br /> S <br /> D Owner Given Reason for Denial 1 vl,(l� I( 6✓ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plain for the tynem and submit to the County only on paper not leu than 9 tax 11 inches in rise <br /> SBD-6398(R-01/07)Valid thru 01/09 <br /> g � oTB <br />