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commerce.wl.gov Safety and Buildings Division Co <br /> 201 W.Washington Ave.,P.O.Box 7162 r t e. <br /> iseonsiunty n Madison, Sanitary Permit Number(to befilledinbyCo.) <br /> Department of Commerce s 2 z 114 14 <br /> Sanitary Permit Application State Transaction Number ,\ <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental I eco) W <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Projett Address(tf 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,s.15.04 I m,Stats. p <br /> I. Application Information-Please Print All Information '3f7.�/ {�$�NN 1g V$cr. <br /> Property Owner's Name / Parcel# <br /> J <br /> A-)6 4 o,�Z S' 9-37,5"- 0 7 70 <br /> Property Owner's Mailing Address Property Location <br /> 36 A C Govt.Lot <br /> Ci//ry�� State Zip Code Phone Number Section <br /> 7 <br /> t.! A-��N r (�.� ® A, 'A, le one <br /> T�N; R circEo <br /> Y4 or <br /> of Builth (check all that apply) Lot# <br /> 4 �or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> Block## -5 r^/AJC G,- AJJ V' <br /> ❑Public/Commercial-Describe Use <br /> ❑City of "--" <br /> ❑Slate Owned-Describe Use CSM Number D Village of <br /> Town of ��O <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) S-70&- <br /> A' ❑New System $Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other 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 /> r / <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> p.Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdst) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> do 7r ? 415-0 9 5, 00 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks <br /> u o <br /> 5 r <br /> h iL 3 <br /> Septic or WdiQ#4;Mm 7✓✓D <br /> Dosing Chamber rte/ <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWT'S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 1,J A ;.4o �P � 7---Z--74'T/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 166 /`/ .S s,^ef IJ /- J 7 <br /> VIII.County/Department Use Only <br /> [Approved ❑ Disapproved Permit Fee �j Date Issued Issuing A nature <br /> ❑ Owner Given Reason for Denial $ �� ✓ ID '09 <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 a 12 a 11 Inches In size <br /> SBD-6398(R.02/09)Valid tbru 02/11 <br />