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eommeree.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 F I.t r n e {�' <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce __540 <br /> Sanitary Permit Application State T an ction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental P.(A.so <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than retailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary O rJS <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1 m),Stats. u <br /> I. Application Information—Please Print All Informationr S 41 <br /> Property Owner's Name //�� Parcel# <br /> 01 i'4dtell �- j u,Mr era/ or o7-ot8- -39-tb-Z -I oa-000-v <br /> Property Owner's Mailing Address Property Locabo <br /> `Ng-33aq-al-a-oo <br /> e�-T,--7 0 !7n e, Govt.Lot <br /> City,State Zip Code Phone Number A11 x j y, �� Section <br /> G� bv S7�30 7/a` 8Yo6- y {��— (circle one <br /> w <br /> II.Type of Bu'di g(check all that apply) Lot# T _N; R E or/W J <br /> 1 or 2 Family Dwelling—Number ofBedrooms—3 Subdivision Name �"'.� <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 7 FTownof WAee+1c-e\ <br /> UI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. pNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑Change of Plumber List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal El Permit Revision g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/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.Dis rsaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(SO Dispersal Area Proposed(sf) System Elevation <br /> 14So 1 .S' IOU `7c)0 12eS- <br /> Vl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o ,a, u <br /> New Tanks Existing Tanks <br /> Z c m a <br /> w` Uo H w h iiU W <br /> Septic Holding Tank K QOO / K <br /> (Tbsing Cham r (0.00 <br /> VII.Responsibility Statement-I,the orders ,assume responsibility for instillation of the POWTS shown on the attached plans. <br /> Plumber's Name Print) Plotbee's Signature MP/MPRS NumberBusiness Phone Number <br /> Imp I er tem I 0-)aSaa les ebb-Y&o6�' <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W r )Cd Tj W e6 �� 1/I S <br /> VIII.Counlyfftepartment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issuedlssuin gen rgnature <br /> ❑ Owner Given Reason for Denial 5 �3�(JG. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach m complete plans for the system and submit to the County only on paper not less than 8 in x r I inches in size <br />