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eommeree.wl.gov Safety and Buildings Division Court <br /> 201 W.Washington Ave.,P.O.Box 7162 y e�r'� !•'. <br /> iseonsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 1551100 <br /> Sanitary Permit Application State TransactionNumbey� <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different than mailing addre <br /> s) O <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary L so <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 m,Stats. 5 �� '3 1 IC. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name ! Parcel#O 7-O ?-o - -/ a.S- <br /> N1)I-Fe r l r evJ�/.tJ 2 X35 O o�=oo3-oi3aoo <br /> Property Owner's Mailing Address Property Location <br /> e 5 Govt.Lot 3 _ <br /> City,State Zip Code Phone Number y., Section <br /> cncle one <br /> II.Type of Building(check all that apply) n Lot# T�N; R E o0 <br /> [4or 2 Family Dwelling—Number of Bedrooms ••C c;2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use D City of <br /> El State Owned—Describe Use -- <br /> CSM Number D Village of <br /> Vj . /7 41—of 41JL'e- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. D New System PRe lacement System y p y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑Change of Plumber 11 Permit Transfer to New <br /> 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 /> ?ANc Pressurized In-Grourd D Pressurized In-Ground D 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.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(so System El tion <br /> S d 900 <br /> VI.Tank Info Capacity in Total It of Manufacturer <br /> Gallons Gallons Units o'o u <br /> New Tanks Fxistie4 Tanks CJ <br /> v o tl <br /> Septic or Holding Tank <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)n Plumber's Signature MP/MFRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> c!>� S/ l 5.:� _ . ) T _:�7 5� 7.z <br /> V[ L Court /De artment Use Only <br /> Approved D Disapproved Permit Fee Dale Issued Issuing Age nature <br /> $ q - <br /> ElOwnerGivenReasonforDenial .f� aZU1f <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 9 I x 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />