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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 u r/v C <br /> isco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 5ZI 19 2 <br /> Sanitary Permit Application State Transaction Number rW <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �— W <br /> unit is required prior to obtaining a sanitary permit. Note: Application fors for 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 3 <br /> purposes in accordance with the Privacy Law,s. 15.04 I m,Stars. /—/C-/o96 <br /> I. Application Information-Please Print All Information Am <br /> Me— <br /> Property Owner's Name Parcel# <br /> G / L a m „l &Z 4 ©/a <br /> Property Owner' Mailing Address Property Location <br /> ?o 3 D-e-e- r ' / Govt.Lot <br /> City,State Zip Code Phone Number y., 'A, Section <br /> 5-e1 d cle one <br /> 11.Type of Buildi g(check all thatapply) / Lot# T N; R / E <br /> Kor 2 Family Dwelling-Number of Bedrooms 3 $ Subdivision Name o / <br /> ❑Public/Commercial-Describe Use Block# b2.�Q„ AJd , (/ <br /> -- ❑ City of <br /> ge <br /> ❑ CSM Number State Owned-Describe Use ❑Villa of <br /> LL <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System �4eplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. D Permit Renewal D Permit Revision D Change of Plumher D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> P41en-Pressurized In-Ground D Pressurized In-Ground O At-Grade D Mound?:24 in.of suitable soil D Mound<24 in.of suitable soil <br /> D 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c -2 o w <br /> ;NewTanks Existing TanksvcyU rn „ H ti0 WSeptic or Haldjpgyak- l <br /> Dosing Chamber Cl <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin!J r / Plumber's Signatu/re MP/MPRs Number <br /> // Business Phone Number <br /> 0 2-1746 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6K spy <br /> VIII.Coun /De artment Use Only <br /> Approved D Disapproved Permit Fee <br /> Date <br /> /Issued Issuing Age i are <br /> D Owner Given Reason for Denial $U3•/w25� <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 in x 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />