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oommeree.wl.gov Safety and Buildings Division Cowry <br /> 201 W.Washington Ave.,P.O.Box 7162 A)e— <br /> i sc o n s i n Madison,W1 53707-7162 Sanitary Permit umber(to be filled in by Co.) <br /> Department of Commence .551 LS9 <br /> Sanitary Permit Application State Tta/ns'�'ctioon'Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental t�lw4�7 kuted �l�V <br /> unit is required prim to obtaining a sanitary permit Now: 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 oV`7 7 �y1ri n_ <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#Q 7 <br /> C-r^ / /n(//Lsf,fC A-) Sf4 � 070 Ss- ©-zzll <br /> Property O`6 wner's fling Adddrress Property Location <br /> Q `� lisp— /067 Govt.Lot <br /> City,State Zip Code Phone Number y, y., Section 1;2z> <br /> m X507 9 -O leon <br /> T�N; RctrcEa <br /> II.Type oPBuilding(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name�1 ,.J1,/L <br /> — Marr ag 26, SLsr c LAke- Ad j. N 0 <br /> 6 / <br /> ❑Public/Commercial-Describe Use �yyal�•r/ <br /> I -1'3-79, 8/X 1 ❑City of I <br /> ❑State Owned-Describe Use CSM Number {❑Village of �- <br /> //� (a d T "own of SGd <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) / 0 <br /> A' ❑New System ,�&Replacement System <br /> ❑Treatment/Holding Tank Replacement Only 01 her 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 steWCom onent(Device: Check all that apply) <br /> pr <br /> ❑N�"�on-Pressurized In-Ground ❑Pressurized In-Ground 11At-GradeEl Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> Yu�kHlllding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> c 7�� <br /> De'si�)n Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(so System Elevation <br /> — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks u c .°_3 2 b, .� <br /> a` V in H h w. U a <br /> .si'wor Holding Tank <br /> Dosing Chamber (/�N <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) p ,r Plumber's Si MP/MPRS Nu ber Business Phone Number <br /> W eke `K/`/ y o/• �7-; y� <br /> Plumber's Address(Street,City,State,lip Code) <br /> oXs�9 sire .-. ` Gds SV�7� <br /> VI .Court /De srter—Use Onl <br /> Pertnit Fee Date Issui ,(rAgent Signature <br /> roved El Disapproved <br /> ❑Owner Given Reason for Denial S 375 <br /> X.Conditions of Approval/Reasons for Disapproval No F14odl. QIt',w Sb,'AI Ba 5 w Wf oa, Ole <br /> St(� —d- <br /> IS kW100bi. as R Xx4- (Math of DaK ,L46 Ir an enyoreerok Afs de'6'V'101aes a ,d F6 kl- <br /> �K /4"c dncC b-w- "iE of tae (W',g G3Hks is Wk.Nt' A � ,Zone AE, !Mies ,uuc6 Le b&O* op <br /> r `ue. Flood ?Vuioef,*l fdeut+6✓.m. � <br /> Attach to complete plans for the system and submtt m the County only on paper not less than 8 Mail inches to sin <br /> SBD-6398(R.02/09)Valid dura 02/11 <br />