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commerce.wigov Safety and Buildings Division County (0 <br /> 201 W.Washington Avc.,P.O.Box 7162 I�Cr�� <br /> tiisconsin Madison,WI 53707-7162 Sanitary Permit Numbcr(to be filled in by Co.) <br /> Department of Commerce 57 g a95 <br /> Sanitary Permit Application State Transaction Number <br /> In accordancc with s.Comm.83.21(2),Wis.Adm.Codc,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 arc l'rojcct Address(if different than mailing address) <br /> submitted to the Department of Commerce. Pcrsonal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owncr's Name l'arccl# <br /> ►JC)n ►wn /ClwvietS / E «iZ -o9//-3c_;3 - cio7e-r) <br /> Property Owner's Mailing Address Property Location <br /> .7'3c 1,0 J D a 10, CA...a n, , V-C. Govt.Lot • <br /> City,State Pre-,' Zip Codc Phone Number S i.J %. 51A) y, Section 3 Ci <br /> SGt,� / t`t Li• ' �`I t v 37 0 ). - 9 (circle one) • <br /> H.Type of Building(check all that apply) L Lot# <br /> T I N; ft I I C or W <br /> NR 1 or 2 Family Dwelling-Number of Bcdroon / U Subdivision Name <br /> Block ft 113 ( , 5 T-,) 1 (jCn/s,,,-s S <br /> ❑Public/Commcrcial-Describe Usc — <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> '- Town of f3(. S tv <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) • <br /> A. <br /> New System y ❑ Replacement System ❑Treatment/holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.ofsuitablc soil ❑ Mound<24 in of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)_ <br /> V.DispersaVfrcatment Area Information: 99 !� <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsl) Dispersal Area Required(sf) Dispersal Area Proposed(sf) Syst GIB • !, '/ <br /> �t�v . 4 /Soo %1 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° o v 0 <br /> New Tanks Existing Tanks W c u '' ; 2 <br /> , 8 <br /> n U inn us w 3 o. <br /> Septic or holding Tank 6 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for i stallalion of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 1Olt'/MI'RS Number Business Phone Number <br /> hrci(cw W. He,.,,i.. l2- ..A--- e--.J. ` • ,) / -6- - 668-X31-S'ic`3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6 13 G47-t- "/c- tic 1.__.- ( J. . 53. 5 <br /> VIII.County/Department Use Only <br /> pprovcd ❑ Disapproved Permit Fee Date lss d Issuing gent Signal rc <br /> S zj c� Q A <br /> ❑Owner Given Reason for Denial �"/J �• i / (3 I <br /> IX. on Lions o Approv casons for Disapproval / p V <br /> q%li 9s. a ' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 811 s 11 Inches in size <br /> be - V62 i 3 ell k-- 1-0 o f cl <br /> • <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />