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commerce.wl.gov Safety and Rt)il4(a( Piwision County", <br /> 2($( W;Waslf{tgt4tu Ave: P.O.Box 7162 4)i." A/= <br /> i se a n s i n Mactis(Sn,WI '1707-7162 Sanitary Permit Number(to be tilled in by -- <br /> Department of Commerce ++? a 60078 <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. Note: Application forms for state-owned POWrS are Project Address(if different than mailing address) <br /> submitted to the Departtnent of Commerce. Personal information you provide may be used Mr secondary <br /> purposes in accordance with the Privac I aw,s.I i.04(I (m),Sr_ Oh <br /> 1. Application Information-Please Print All Informs�l as w. A al. lit 16(i`LIA , pea <br /> Property Owner's Name Parcel t <br /> A> let E. E APR 1 2016 O3 t ci 96 7 /t / - 7i -I <br /> Property Owner's Mailing Address Property f ucation <br /> 794 4,1,41e/if - Public Health MDC <br /> Environ1T ntal Health G„tt.I of <br /> City,Sta Lip Code I'r me Number — <br /> / <br /> , 1� Section r� c.-4/ ry 143:;(-7_5(.:, (code one) <br /> /2).9 re f.c tti1 5337 c t"C i .I N; ,t 1 K.&W <br /> II.Type of Building(check all that apply) u t.ot is <br /> B-I'`r 2 1mnily Dwelling-Number of Bedrooms ` f Subdivision Name <br /> Block t <br /> ❑Public/Commercial-Describe Ilse —__I <br /> ❑City of <br /> ❑Slade Owned Describe Use CSM Number U Village of <br /> Q=luwnor t(cst-i3 k(Z ; <br /> 1 Lit s2 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. k:Kew _ <br /> ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Refute Expiration Owner <br /> IV.Type of POWTS Systent/Contponent/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade U Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ holding Tank t53CCuher Dispersal Component(explain) CZ--"'l,,,,t,/ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area information: ° S'QC t ,, . , <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsl) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Flevution <br /> LP LC r 5 (ZCn d Z.c,r. 3(C -.J:v .( - ' v <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o"o L v NewTanks Existing Tanks c = ■ iv s u .1-.,.. <br /> A--U v: N <br /> r% LT,i.-5 a. <br /> Septic or Prattling Tank (_:C r 1 <br /> _ 1 Z ( �C i We art k l y > /k ' <br /> Dosing Chamber , C} .PC.,6 r rt//f55i''1 !6'J#i <br /> VII.Responsibility Statement-I,the undersigned,ass ne res. ibili 'for installation of the POWTS shown on the attached plans. <br /> Plumbe is Name(Print) Flambe stign• MP/MFRS Number rBusiness Phone Number <br /> /4-e. (y/2?elf ti 16-4-') 'l 35 ( t C€S- 1:4 3--i'5 <br /> Plumber's Address(Street,City,State `.ip Code) <br /> 'Jt' /9' t#t St ez 41,0e 'S4 cr 35I} <br /> VIII 'ounty/Uepnrtment Use Only _ <br /> Permit Fee Dale Issued Issuing A� nature <br /> Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial f �� ��% // /�. <br /> •IX.Conditions of Approval/Reasons for Disapproval <br /> t 3) 8D 3r E2-Fl ow skis = 1200 SQt FT 6./;47 A, <br /> VV ".. C-.M RA-rt. re ,4ø r ' 'F execAc 3'0' Pose rwir pis/v./c/o. <br /> Is &fro_ yMr62 Th oucc. {.Many cise Fax.M 1339 -= IZa1 <br /> Attach to complete plans for the system and submit to the County owls mt paper nut Less than It ties t t inches in sire <br /> SI3D-(s395(R.02/09)Valid Rini 02/11 <br />