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COff1merce.Wl.Qov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 n 2 <br /> 1 SW a ns i n Madison,WI 53707-7162 Sanitary Permit Nu ber(to be filled in by Co.) <br /> me <br /> Sanitary Permit Application State Transaction Number 63 <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental se-)ece� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned M w I a are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m,Stats. <br /> I. Application Information-Please Print All Information !f d e O <br /> Pr erty Owner'g Name n Parcel# r) <br /> r tl /.J eve �S C 0,2- c>0a- oov <br /> Property Owner's Mailing Address - Property Location ,t1 Fr to//Z <br /> City,State Zip Code Phone Number StJ yy Section /1 <br /> v (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> ❑I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑PuBlock#blic/Commercial-Describe Use i <br /> LJ City of �— <br /> ❑State Owned-Describe Use / <br /> CSM Number 1:1 Village of <br /> R-Tewn of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) Q <br /> A. New System Replacement Li Treatment/Holding Tank Replacement Only LJ Other Modification to Existing System(explain) <br /> ystem <br /> B. Permit LJ Permit Revision Change of Hpt.it Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.T e of POWTS S stem/Com onent/Device: Check all that a I <br /> Non-Pressurized I SGround Pressurized In-Ground At-Grade Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> P-Uolding Tank ❑Other Dispersal Component(explain) ❑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 /> U <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks z0 m <br /> v a <br /> 8epticurHolding TackI Ll 10 1 El El <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(Pr' t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a A- 5 /S� Srf e /-i <br /> VIII.County/Department Use Only <br /> Approved _ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> Owner Given Reason for Denial $ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> jli / a.�, <br /> U; A)o &urEyb)e A✓ea Pr d w,I H6�a0661'r Ca/l /S aoatla6/e �r �yv Ey � St�a. <br /> Ar-2- r5. J.O, Ses/ /5 -*XV6l4C. <br /> vd iAXt(,A,- t6A -Lotus- Ala. a cu»r lat a,eC .1- W.l 4/or>� NooK <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2:11 inches in size <br /> SBD-6398(R-01/07)Valid thru 01/10 <br />