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' 10/12/2009 13:37 FAX 2625604795 ()Mal1eyEom .* Eio01/002 <br /> . --diatir- , Coll merce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 e <br /> Isconsin DD Madison,WI 53707-7162 Sani N be t be J Co.) <br /> .epartment of Commerce 1 <br /> State 1 ransaction Number • <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS 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.15.040Xm)_,_Stats. 2051 t <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> M1142 )k L rn 1)Ag <br /> coi <br /> Property Owner's Mailing Address Property Location <br /> 'rib& NebrftS PA-GU- CA- Govt.Lot <br /> City,State Zip Code Phone Number NE 'A, NIV4 'b, Section 2'7 <br /> IVIC '41-4(sote W l a S.1?- as ' (circle one) <br /> II.Type of Buikling(check all that apply) Lot# T �O N; R 1 ]ssrw <br /> yi or 2 Family Dwelling-Number of Bedrooms 4 .4 Subdivision Name <br /> Block# '^ <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> i2213 yt Town ofPke t4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. w System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I <br /> IL ❑Permit Renewal ❑Permit Revision Change of Plumber Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration er <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> rl Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tanks, ❑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 /> .4 1,e3D0 1,512 elo.o`-r),7.4, <br /> VI.Tank Info 1 Capacity in I Total #of Manufacturer l <br /> Gallons Gallons Units o I o ti, o <br /> New Tanks Existing Tanks .: "• , 1i ' A Li <br /> c,U in rn j 3 a. <br /> Septico.ll.k1wgTank--- iL ,— 1:26 1 ivtewte, X <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) Plumber's Signature -1e'/MPRS Number Business Phone Number <br /> -,L ,&-etAj l'J - N�iY\ <2 - ,C"_-- 60:'-?'-\ 220 i&,. 8F,1-arG� _ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> I <br /> Permit Fee Date Issued Issuing Age. '..atur./ . <br /> PProved ❑Disapproved cl , � <br /> ❑Owner Given Reason for Denial big <br /> O <br /> IX.Conditions of Approval/Reasons for Disapproval . <br /> Attach to complete lam f o r the system and submit to the County only on paper not less than 8 ins I I inches in size <br /> b )1-' q 5cY6 j+(/-jy .00 -rr'fafl 2 <br /> CAA— {5roc 'R iV 1SION <br /> SBD-6398 x,39\\8(R.02/09)Valid thru 02/11 <br />