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t '1'I , e Aso f II�1'( commerce.wi.•- L. Safety and : 7 9'tI•s Division County .� L 201 W.Washington Ave ,P.O.Box 7162 0a,,�e_ , ' tI S Cc n I bll-c •iw«It:P .a: 53�07-7162- - _ - - - Sanitary Permit Number(to be filled in by Co.) — ,EL Department of Comm En ironm ntui I.',`ith 5a v 3o p , Sanitary,Permit Application State TransactionNumber In accordance with s.Comm 83.21(2),Wis.'Adm_Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. � A C- I. Application Information-Please Print All Information Property Owner's Name Parcel To 5.e pit - Alit as1a re 05¢- 07c7 - -. 13 '-� q QC�1 -- O Property O er's Mailing Address ((��/° Property Location 7? P(�'f'r / 1I�e Govt Lot City,State Zip Code Phone Number S'(,0 y JIA.) �'A, Section '1 � j > /'r aGQf Son l 5 Q (circle one) T p N; R 7 EorW H.Type of Building(check all that ap ) Lots gi 1 or 2 Family Dwelling-Number of Bedr ms 11 ' J Subdivision Name • Block' ❑Public/Commercial-Describe Use �\ ❑ City of ❑State Ovvred-Describe Use OM Number ❑ Village of //�� Iii Town of *JQ ir.ey /6350 // III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A_ .New System Yv y . ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Eristing System(exTlain) B• ❑Permit Renewal • • 0 Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Daze Issued Before Expiration Owner IV.Type of POWTS System/Component/Device: (Check all that apply) • ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade RiMound>24 in.of suitable soil ❑Mound<24 in of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) • V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation • oat? I. 0 600 boa 113r VI.Tank Info , Capacity in Total #of • Manufacturer Gallons Gallons Units o New Tanks I ads-61g Tanks o j • cm eptic., 'oldng Tsk I i/2._5,,. ,!�, I I// t�C I / I /'c Pa e(r- I w easing Ch n.s I 6. �V I 65-dI t' I Aeal-e I ? I I VII.Responsibility Statement-I,the undersigned,assume respons'•ility for installs'',:•of the POWTS shown on the attached plans. Plumber's Name(Print) PI u.ber's Sip, M2MIPRS Number Business Phone Number n r Plumber's Address(Street,City,State,Zip'tode) 1 v 7 '3G l Oct%l ►,t t,ise Cr 0aec€ Lc 5-3.5 z9 VIII.County/Department Use Only / • Approved ❑Disapproved. PetmitFee n Date Io ue IssuinaAgen i. - e 6 I / ❑Owner Given Reason for Denial ��O�i(7 �� 9 Pi i ! � C A'FOiAi, DPttC G�JId LX. Conditions of Approval/Reasons for Disapproval ENVIR^, i 'l AL HEALTH DOES NOT HOLD I 'SELF LIAB,: •R ANY DEFECTS IN PLANS OR SPE, !FICA- . Tit S, PLAN OMISSIONS, EXAMINATION OVE. - • SIGHT, CONSTRUCTION OR ANY DAMAGE TH T MAl RESULT IN OR AFTER INSTALLATION AND RE.ERVE: Attach to complete plans for the system and submit to the County only on paper not less th ililfi cS.eet/O&DER CHANGES OR ADDITIONS DB— ��11 1 Ck v` I ( f C i( G�s_- RevGCW SHOULD CONDITIONS ARISE MAKING THIS SBD-6398(R.01/07)Valid thru 01/09 -j J `P '�1ECESSARY. �6D� f fr"u •