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Itoommerce.wl.gov Safety and Buildings Division County <br /> i1 a 201 W. Washington Ave., P.O. Box 7162 L', <br /> sco n s i n Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> , of commerce ON COMPUTER/SCAN ED 53a3 <br /> Sanitary Permit Application State Transaction Number Q <br /> In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate J 9 -L <br /> governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned Project Address(if different than mailing address) <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stars. � (7 J' <br /> I. A I3tr I Co . <br /> kApplication Information-Please Print All Information <br /> Pr rt Owner's Name Parcel# <br /> A. <br /> W >J z 4//,j r, �a 3 6a7 yiad - c, ;2 --wo <br /> Property Owner's Ma iling Address n Property Location p <br /> 1371 � i� J Govt. Lot a <br /> City,State Zip Code Phone Number p�/// 16, Sf,Section 6 <br /> 5 o o.v e r 4-) �y�0 G/ d/b(� (circle one) <br /> II.Type of Building(check all that apply) Lot# T '/0 N; R IY E o® <br /> 124 or 2 Family Dwelling-Number of Bedrooms a;2- Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ❑ Town of S c o AL <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑ New System XRe lacement System y p y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. El Permit Renewal El Permit Revision El Change of ❑ List Previous Permit Number and Date IssuedPermit Transfer m New q <br /> . <br /> Before Expiration Plumber Owner �35 3'Z <br /> 7904 co/ Avg a,+ 2U0,3 <br /> 1 <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in.of suitable soil Mound < 24 in. of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Desi n Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a _ <br /> New Tanks Existing Tanks w c u _ <br /> P o <br /> a U <br /> Septic or HoWiog.Taak <br /> Dosing Chamber <br /> 7.5-0 <br /> C— <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's NamePrin [) Plumber's Signa cure MP/MPRS Number Business Phone Number <br /> �Sl <br /> Plumber's Address(Street ,City,State,Zip Code) <br /> 16OX S/`/ si/' e iJ <br /> V I. Count /Department Use Only <br /> Approved El Disapproved Permit Fee Dale Issued Issuinggent SSignature <br /> El Owner Given Reason for Denial $3T5 oD -'��/C) <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 8 1/2 x 11 inches in size <br /> SBD-6398 (R. 02/09)Valid thru 02/11 <br />