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connnnerce.wi.gov Safety and Buildings Division Cmmay SI <br /> 201 W.Washington Ave.,P.O.Box 7162 B4, Y h t,1 <br /> is eo n s i n Madison,W1 53707-7162 Sanitary Pe mit Number(to be filled in by Co <br /> Department of Commerce S32/2 3 <br /> Sanitary Permit Application State Transaction Number <br /> r1naccordance with s.Comm.83:21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (/i(p�//s j <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-ownd POWTS are rMjectAddress(if different than mailing address) I ry <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary ! I 1 <br /> oses in accordance with the Priv Law s.15.04(I)m,Stats. '// n I,,��� ,,f�'� v 1 <br /> I. A lication Information—Please Print All Information I ID'I a �y(� rOI,U Gls <br /> Property Owner's Name �{.. Parcel# n-t�r <br /> furl/4 �CciS -oi -3 3 �!6-n3 0 <br /> Property Owner's Mailing Address <br /> �O Property Location <br /> City,State Govt.Lot <br /> ! r <br /> Zip Code Phone Number <br /> 6 ', / f� �G S�C� % Section <br /> �r S�P 7.3 76 `�qq ucle one" <br /> IL Type of Building(c heck all that apply) Lotg �� T_L_N; R. 0(l4/. <br /> &61 ort Family Dwelling-Number of Bedrooms ______ Subdivision Name "`CCC_ <br /> Block N V/Cdr <br /> ❑Public/Commercial-Describe Use r <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Town of /W eto it 0)-X <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑News tem <br /> Ys �Replacement System ❑Trcatmrnt/Holding Tank Replacement Only ❑Omer Modification to Existing System(explain) <br /> B• 0 Permit Renewal ❑Permit Revision ❑Change of Plumber 0 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 /> 0 Non-Pressurized In-Ground 0 Pressurized hr-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 19 Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) <br /> ❑Pretreatment Device(explain) <br /> V.Dis ersal/TreatmentAres Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area P <br /> - Pe roposd(st) System Elevation <br /> VI.Tank Info Capacity in Total N of <br /> Manufacturer <br /> Gallons <br /> Gallons Units ti d <br /> New Tacks Existing Tacks <br /> c. V v, y wC7 a <br /> Septic rHolding TaNc / <br /> osing hamber <br /> VII.Responsibility Statement- 1,the undersigned, ssume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plu er's Signature <br /> MP/MPRS Number Business Phone Number <br /> S Lloe r{dp✓ Z i Sza lis�?s646 00 <br /> turner's Address(Sheet,C/iry' ,State,Zip Code) <br /> 7 C 60C �d � �ve6s4er t. <br /> /DSi�P,3 <br /> VIII.Count e artment Use Old <br /> D Approved ❑Disapproved Permit Fee Date Issued Issuing tgnamre <br /> ❑Owner Given Reason for Denial $ 3 75� 2/A �9 <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> �l. ��d �zrg,d/e mat/u✓v S�Zo/v9 <br /> Attach to complete plans for the system and submit to tae Cooety only ae paper not less than 8 12 x 11 inches io size <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />