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commereeml.gov Safety and Buildings Division Coun <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> IIS onsin Madison,WI 53707-7162 Sanitary Permit Number(tobe filled in by Co.) <br /> par e of.Commeroe -5-40 <br /> M <br /> 11 Sanitary Permit Application State Transaction Number <br /> In accordance with s.efornm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental [O 17 1 yU7 _ <br /> unit is required prior to obtaining a 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 PrivacyLaw,s. 15.04 1 (m),Stats ;' -I 5 —/z- 541rw)w A_ L <br /> I. A licatian Information Please Print All Information Cf / T c.J///444 �`t�d(Je <br /> P 'e' wee's Na c I ( Parcel# n 7OL <br /> ro000 <br /> Property Owner's Mailing Address/ Property Location <br /> 3 ^ 1+ Af C'� Govt.L�o't <br /> City State Zip Code Phone Number y y Section <br /> / �`irek ) <br /> Tyore <br /> - --- - — - -- u R _b o I <br /> II pe of Building(check all that apply) Lot# - <br /> [X1 or 2 Family Dwelling Number of Bedrooms SooJivis on Name <br /> Block# <br /> ❑Public/Commercial- Describe Use El city of <br /> CSM Number -_ �_ <br /> El State <br /> Village of State Owned-Describe Use --- _ _ — _._.__-_ <br /> -'Powe of <br /> III.Type of Permit: (Check only one box on Ince A Complete line B if applicable) <br /> A O Nmy�'ystcn7 ❑Replacement System YTrcatmenUl --_ _— El Other Modification to Existing System(explain) <br /> -SIT List Previous Permit Number and Date Issued <br /> B. FII I Patine Renewal El Permit Revision El Change of Plumber El permit Transfer to New <br /> Bdfore Cxpiratmn Owner <br /> IV.Type of POWTS System/ComponenUDevice: Check all that <br /> ❑N n-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil Mound<24 in of suitable soil <br /> IFI i. <br /> $II _ _ <br /> }I IJing I's nk (I Other Dispersal Component(explain) _ - __ - —.--_ ❑Pretreatment Device(explain)_ <br /> is ersallTreatlnent Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdst) Dispersal Arca Requirrti(sf) Dispersal Arca Proposed(sf) System Elevation <br /> I _ <br /> i <br /> VI.Tank lnfU Capacity in rulnl #of Manul'aUuar 2 <br /> Gallons Gallons Units g U <br /> c <br /> New Tanks Fxi.oing Tank, <br /> a U in vy, � ii V L <br /> 8ocTu <br /> ptic or Ilolding nk <br /> 'ng Chamber <br /> VII. ,Responsibility Statement-Ithe undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> - _ _ — _-- <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone'Number <br /> i✓� '/�f/,3 �. � � —r zz76 9/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VII Cop n /Pt. artment Use Only _ _ -- - <br /> Permit Fe, Date Issued Issuuig a signatum <br /> Owner <br /> Give <br /> � I � isa S <br /> IX �o i ved � cr Given Reason for Denial � ( ���` 1�- D� <br /> PP <br /> editions o!ApprovaVReasons for Disapproval <br /> _ ___.— <br /> I <br /> Attach to complete plans for the syslens aad submit to the County only on paper not less Ilton a va a 11 Inches In size <br /> SBD-6398(R.01/07)Valid than 01/09 <br />