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`ZbW1 llC.5-- <br /> commerce.wi.gov Safety and Buildings Division CounU0.0 201 W.Washington Ave.,P.O.Box 7162 Q <br /> is c o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 5 17 9 Li 4 <br /> Sanitary Permit Application State Transaction Number <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. Notc: 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.15.04(1)(m).Slats. r72- 7 R / / / ' <br /> I. Application Information-Please Print All Information L /L CJ At, <br /> Property Owner'is Name Parcel# <br /> Tow f _A-Ril 7 /& 0808- 211- q _o <br /> Property Owner's Milin WA0vK s Property Location <br /> er1 1 7 , 4( <br /> Govt.Lot <br /> /City,S r/�]' Zip Code Phone Number %, , <br /> l r W ie t cob VT 3-33-62_ •, I Y� /. Section ) <br /> (circle one) <br /> IL Type of Buildit�g(check all that apply) Lot# T N; R E aril*' <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of p ��j /� <br /> /2029 %Town of £ eeW- j C 6Ly <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System ❑Replacement System XTreatment4koldiag Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and1Date Issued <br /> Before Expiration Owner f 7`1 36Lel 2,--c7S—zr) g zs-12 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> SNon-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 /> Design(gpd) Design S�Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevati <br /> [ 30 / / 0E0 ' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units a E o'g °_ <br /> New Tanks Existing Tanks v = u 9 °u 1 <br /> A <br /> U iY c r w C7 <br /> C. <br /> Septic erlield ng Tank /000 X <br /> Dosing Chamber O O Zee j 1 c / <br /> 600 <br /> h <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 MP/MPRS Number Business Phone Number <br /> Timothy J Jelle f <br /> r -tl-n 1r�,� T_,1Q 227525�. 608-845-7466 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> . <br /> 501 Commerce Parkway Verona Wi 53593 4Z 461 <br /> VIII.County/Department Use Only <br /> .pproved ❑Disapproved Permit Fee Date Issued Issuin t Signature <br /> S29S• oo 4-?-08 v X � _ <br /> ❑Owner Given Reason for Denial Q �/ <br /> IX. <br /> Conditions of Approval/Reasons rDisapproval <br /> �4/1" ,4-�Cp -.�I`�7i-"1r i ©F //. 2 l �F�l� <br /> • <br /> Attach to complete plans for the system and it to the Count only on paper not less than 8 irz z 11 inches in size <br /> • SBD-6398(R.01/07)Valid thru 01/09 <br /> P-13-1(6 VI cik 3 l`f7° <br />