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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Q <br /> 4& CAJ <br /> isconsin Madison,W153707-7]62 Sanitary PermitNumber(tobefilledinbyCo.) <br /> Deparhnent of Commerce 6z l r-. 427 <br /> z <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 (/ut; g yC(,r,J <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POW'IS are Project Address(if different than mailing address) <br /> submitted to the Deparnnent of Commerce. Personal information you pr vide may be used to. secondary <br /> u ores in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> 1. Application Information-Please Print All Information -5/`jt^i �- <br /> Property Owner's Name Pat-]# e Cr -Z 7j (3 2 5/ <br /> C -3 000 C5 13or:� <br /> Property Owner's Mailing Address Property Location <br /> 88 SO G �z 5 � /J7a>oF-b E&22.3 ci: 6kz <br /> City,State Zip Code Phone Number <br /> _�/ -7 �'/4, 5 `/., Section��7 <br /> f�`4 /� W'� .7 /8�� �S� -���s` 3 T_%LN; R- (circle—Eon <br /> II.Type of Building(check all that apply) Lot# <br /> D 1 or 2 Family Dwelling-Number of Bedrooms � - Subdivision Name <br /> _ Block# �- <br /> D Public/Commercial-Describe Use <br /> D City of <br /> 11 State Owned-Describe Use 7CSMumber D Village of <br /> ~ 'Town of /I <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) 03 _ 533-�-Oa <br /> A. <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply <br /> rNon-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> ❑ Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> vo / 7 `71o� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ��`°, V - <br /> v <br /> Septic or Holding Tank 75-0 7S6 <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print}, Plumber's Signal= MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -5- <br /> VII .Coun /De artment Use Only Approved D Disapproved Perni[Fee Date Issued Issuing A n igna[ure <br /> ❑Owner Given Reason for Denial <br /> $ .ZS�po .7/Aurae 11011 <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 1/2 x 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />