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commerce.wLgov Safety and Buildings Division County <br /> 201 W.Washington Ave,P.O.Box 7162 Burr e_# <br /> IS <br /> n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1)epartmant of Commerce 54D 3 3 <br /> Sanitary Permit Application State Tn on Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental vt Ln e4,) <br /> unit is required prior to obtaining a sanitary permit Note: Application forma fm 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 1 <br /> purposes in accordance with the PrivacyLaw,a.15. 1 m),Slats. 8 y yT /7 I n rj sn d Rd. <br /> I. Applimlion Information-Please Print All Information <br /> Property Owner's Name Parcel N o 7.0 3 t -VO•17-3 -S' <br /> J&PArt Solye a J5-S-77- 011000 <br /> e <br /> Property Owner's Mailing Address Property Location <br /> 66 / 3 Sh< m. , Ca Rd GovL Lot <br /> City,State Zip Code Phone Number <br /> v., v., wenn 3 6 <br /> G1n0 Lake) /h/✓ S.rev38 (tack one <br /> IL Type of Building(check all that apply) ,At l.ot g T 40 N; R 7 E or�V <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms A Subdivision Name <br /> Block# T)W. elnts <br /> ❑Public/Commemial-Describe Use J <br /> ❑City of <br /> O Stale Owned—Describe Use CSM Number ❑Village of <br /> El Town of Gtr ton <br /> III.Type of Permit: (Check only tate box on line A. Complete tine B if applicable) C) — <br /> A. 0 New System Wr Belacemenl System 0 Trestmeat/Holdin TsmkBePlacememt Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision change List Previous Permit Number acrd Date hawed <br /> ❑ Chang ❑Permit Tnnfer to New <br /> Before Expiration Owner <br /> IV.T e of POWTS S stem/Com mrent(Device: Check all that apply) <br /> 2 Non-Pressurized In-Ground D Pressurized In-Ground D At-Gude 0 Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 OtherDispersal Component(explain) D Prelreahnent Device(explam) <br /> V.DispersaVIrmatment Arca Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 300 7 V0k4 c{ 3d 91A- Q5 <br /> VD.Tank Wo Capacity in ToW N of Manufacturer <br /> Gallons Gallon Unita }y to� yr ,y <br /> New Tanks Existing Tanks SRS s i h�' <br /> Cl m <br /> AW A. H RO 0. <br /> Septic or Holding Tw* 800 7fOD / SK9w X <br /> Dosing Clamber <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 Signature ME/MFRS Number Businem Phone Number <br /> R1611f #, kens r w.aC {� oZJrB'd'Sl 7/S—Sb16_41/,r7 <br /> Plumber's Address(Strect,City,State,Zip Code) <br /> 7740 //soy 3S websf-e wt tHS9_? <br /> VI Court /De artment Use Ont <br /> Approved ❑Disapproved Permit Fee Date hewedharm ignature <br /> ❑ Owner Given Reason for Denial 1 <br /> $3,25 2DI0 <br /> IX.Conditions of ApprovaVRessons for Disapproval <br /> Attach eicomplete plan for the systm and subsea tithe Couudy seiy m paper rot lesethan g in all Inch,Ind. <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />