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• <br /> • <br /> OCT 6 204 eck III liSy73 Darn 8 7,21 <br /> commerce_wl.gov Safety and Buildings Division County <br /> 201 W.Wallington Ave.,P.O.Box 7162 a-.4,� <br /> 'S eO N s m 'Madison.WI 53707-7162 Sanitary Permit Number(to be filled n by Co.) <br /> Department of Commerce e 5/8/ 9 <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 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 j(m),Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> le-ciicrc/ IP e i, e.S 0711-- wiz-8,23o — <br /> Property Owner's Mailing Address. S,... Property Location <br /> 4684 l:G! 1 cic-% Govt.Lot 0Z <br /> City,State ` Zip Code �7 Phone Number 4�E yy 4V14) y,, Section Oy <br /> C04� Gam;C LIT d / ��0 .1 ‘ T ) N; R a/ ( 0• W <br /> IL Type iif Building(check all that apply) Lot# <br /> A <br /> 111 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Bloc # <br /> ❑Public/Commercial-Describe Use • <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number p❑Village of <br /> /7 2 p1 Town of C tee (;,r,✓e <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System &Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal El Permit Revision ❑Change of Phnnbcr ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> I <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 51 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 /> 1 V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Disposal Area Required(s1) �E anal Area Proposed(af) System Elevation 1"if <br /> `/S4 L //r $ /,k7 3.A.. �y fv:o 7,5-o' vs'so <br /> VL Tank Info , /Capacity in Total #of Manufacturer <br /> Gallons Gallorns Units " o$ <br /> New Tanks Existing Tanks 1 c $ °o In m V. <br /> Coptic_ sir Holdug Tank x. <br /> L_ /may c� �.w a ,o<��t�,� <br /> Dosing Chamber <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS�shown on the attached plans. <br /> Plumber's Name t) Plum s S" tart �/lvIPIZS Number Business Phone Number <br /> (� CC II <br /> SN��, C.Pt,// �----� 257K5-1 ei,g- -css--e 3 <br /> Plumber's Address(Street,City,State. Code) i <br /> ii <br /> VIIL Comity/Department Use Only <br /> Li Disapproved <br /> Permit Fee Date Issued - Issuing • .eat Signatur ITV <br /> ❑Owner Given Reason for Denial -32C L b "1 �� /_�`_- <br /> Condifiots., Approver .for Disap rp _ `cep Y, _`'1- "'" ra, , >, ' (.„,v_ <br /> ( Ga4{'1(A-� _- 2t /t'�P9 G .0 ,' /vl i+> L <br /> Attakci to complete plans for the system and submit to tin °ol dy only on paper not less than 8 in all inches in awe <br /> SBD-6398(R.01/07)Valid thru 0I/09 <br /> a <br />