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ON COMPUTER/SCANNED <br /> commeree.Wi.gov Safety and Buildings Division County �L <br /> a 201 W.Washington Ave.,P.O.Box 7162 Ba#,A C77 <br /> i seo n s i n Madison,WI 53707-7162 Nee ary Permit Number(to be filed in by Co.) <br /> tiDepartneent of Commerce 1521011 <br /> 2 / O „ <br /> Sanitary Permit Application State Trmnaction Number <br /> In accordance with a.Comm.8321(2),Wis.Adm.Code,submission of this form to the appropriate goventmeNsI <br /> unit is required}riot to obtaining a sanitary permit Note: Application forms for etateowned POWTS we Project Address(if different then mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used fm secondary <br /> pumpoees in accordance with the Priv Law a.15. 1 m,stats. �9 C r,I t en g N�y�ery (1 <br /> L A a <br /> i tim Information—Please Print An Wormatiort / J / XJ <br /> Property Owner a Name Parcel# <br /> 6:lee) Tl4om,4s, p .3� odo-gobs-o} �a <br /> Property Owner's Mailing Address t <br /> - Property Location <br /> 3S'7d Zia;/ 1?1d e 4/ Govt Lot <br /> t eve <br /> City,state Zip Code Phone Number <br /> Yy Yy Section <br /> Wse��je r /m IV $3 /els-- (c- it <br /> Type of Building(dnedn all that apply) Lot IL T T e N, R <br /> # <br /> ,910r2FamilyDweEim9-NumberofHedm= I� Subdivuian Name <br /> Block# <br /> 11PubRmmererib <br /> dCocial-Dese Uae <br /> tong- <br /> 0 City of <br /> ❑State Owuad-Describe Use CSM Number ❑Viugc of <br /> ffTown of Or7k/en twit <br /> IIL Type of permit: (Check only ane box on rete A. Complete tine B B'applicable) <br /> A New S stare ❑ <br /> Y Replacement System ❑Trentmenf/Holding TaolcReplacem®t Only ❑Other Modif'ration to Existing System(explain) <br /> B. ❑Pemrit Renewal ❑Permit Revision ❑assageomuober ❑Permit Tmm;fert New ListPmrioua Permit NumbermdDatlmW <br /> Balm Expiration Owner <br /> IV. of POWTS slem/Can e.tt/Device: Check all that apply) <br /> [''Non-Pre -aced In-Cnound ❑pressurized(n-Gmmd ❑At-Gmh ❑Mound>24 in.of suitable sod ❑Mored<24 m.of suitable soil <br /> ❑Bolding Talc ❑other D spenal Compmmt(eaplaiu) ❑Pretreat ant Device(explain) <br /> V. aVl'ratmmt Area Warmation• <br /> Derigo Flow(gpd) Derigo Soil Application Rate(gpdst) Dispersal Area Required(at) Disports Area Proposed(et) Syskm Elevation <br /> Oso 7 �r3 64a '7 70 <br /> VI.Tank Info Capacity in Total #of Mamm9ctrer <br /> Gallon Gallon Unit o <br /> New Termks E®Cng Twda CC88ii <br /> Septic or Holding Tank <br /> ar <br /> VIL Responsibility Statemmt-L the undersigned,mume responsibility for installation ofthe POWTS shown on the attached pima. <br /> Plumbe.Name(Prot)) Humber's signature <br /> MP/MItRS Number Business Phos Number 7 <br /> plumber'.Andrm(Sheet,(;ary,Sot,Zap Code) <br /> 77 61 r 3S /NebSl�er ltJr _frY�3 <br /> VII Cams 7De ma intent Uae Ottl <br /> Approved ❑Diappmved Permit Fon Date Issued Issuin Sigaamre <br /> $300 Jv <br /> T OB <br /> ❑owner Given Reason fm Denial <br /> IX.Conditions of Appr &Maraca for Duapprovd <br /> Alheh to cumplets phw for the sy>Qess and onbmak to the Conary only on paper mot Was Ware 8 m x 111uetses b.Ira <br /> SBD-6398(R.01/07)Valid then 01/09 <br />