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commeree.wi.gov Safety and Buildings Division County / // <br /> 201 W. Washington Ave., P.O. Box 7162 r)iv44 <br /> �(i seo n s i n Madison, WI 53707-7162 Starts Permit Number(to be filled in by Cc ) <br /> l epartim,ant of Commerce <br /> Sanitary Permit Application State Tmnaa"`on"amber <br /> In accordance with s.Comm. g3-21(2).W is. Adm.Code,submission of this form to the appropriate governmental (') <br /> unit is required prior to obtainine a sanitary, permit. None- Application forms for state-owned POWTS are Project Address(if different than mailing address) �l <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(1)(m),Slats_ (� <br /> 1. Application Information-Please Print All Information �- <br /> Propem Owner s Name Parcel N <br /> v + at�II V, S��-� �- . 3a a of-DL- <br /> Pro <br /> peFty Owner s Mailing Address Property Location St <br /> S3 -7 (Ce 1/Govt.Lot <br /> Cin.State Zip Code Phone Number '/. — 1 l <br /> q _ _ , Y., Section —� <br /> IS, � I � 1 � . le on <br /> 11. T. a of Building(check all that apply) Lot a T 5�0 N; R ( E <br /> 'P'I or 2 Family Dwelling-Number of Bedrooms -� a=1'3 Subdivision Name <br /> Block k <br /> ❑ Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> XTown of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treatmenl/Hold ingReplacement Only ❑ Other Modification b Existing System(explain) <br /> R. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration (honer <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> PR Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ AI-Grade ❑ Mound 124 inof suitable soil ❑ Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow rapid) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3o() , '7 `21 `f—o d <br /> VI.Tank Info Capacity in Total P of Manufacturer <br /> Gallons Gallons Units o o <br /> New Tanks Existing Tanks <br /> a` a , v LZ (_:i a <br /> Sepuc r Holding Tank X 7 SO i <br /> Ibamg Chamber <br /> V 11. Responsibility Statement- 1,the undersignesure rPt) Pluassume responsibility for installation of Me POWTS shown on the attached plans. <br /> Plumber's Name Pri 0 Plu tier's Signature / MP/MPRs Number Business Phone Number <br /> �)P15 ee� r t��, 22V zz.y 715 � &6qd� <br /> Plumber s Address(Street,City,State,Zip Code) <br /> 7 BSS �K �� Z� l t1P�s °f ✓I' <br /> Vlll oun /De artment Use Onfy <br /> Approved El Disapproved Permit Feeee/� Dalelssued Issuin ge ignature <br /> ❑ Owner Given Reason For Denial $ v` 5a� 06607 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Mach to complete plans for the system and submit to the County only on paper not less than 8 In a 11 inches in size <br />