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! <br /> : D)t 1 <br /> 1 <br /> JAN 2 8 2009 1 <br /> commerce.wi.gov 1 Safety and Buildings Divisi,n County .1 <br /> MLA/.WashingtonAvc.,P.s t •x 7Iel2 !J a -. <br /> I L,:a 1'1 S 1 n 1iv[li ftrIny rs#9 .!th S.inittaa y Perr niitNNuumber(to 7be filled in by Co.) <br /> FJ?virt�r�rrlr n r..l F ,;<!th t J! 5 3 <br /> Department or Coottnai'oo - <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with a.Comm.S3.21(2),Wis.Mm.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 lhanmailingaddress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> _j uses in accordance with the Privacy Lax!,s,15.04(I)(m),Slate. <br /> I. Application Information-Please Print All Information ----___ _-_ _ _ <br /> Property Owner's Name Parcel 8 <br /> r.)•• . I ear f . 1 -a r T 4..-m-.-,* t i t a I Z. -O1 t I- 3 0' -- eil, 9-a <br /> Property Owner's Mailing Ad. <br /> Property Location <br /> 7 Cr d'l 3 j� � <br /> RA I Govt.Lot <br /> City.State 4. ' / Zip 0715-.353Z°Number ,51 I 5 t.J k Section 3 o <br /> '.. •- , (circle one) <br /> c i /�/ -..�, W .� f y — T / N. R // L,or W . <br /> II.Type of Building(check all that apply) 9/ tin P . <br /> I or 2 Family Dwelling-Number of Bedrooms T Subdivision Name <br /> -- BI. Soo/ Cos...•cJe+-.+..5' - <br /> ❑Public/Commercial-Describe Use r d City Of <br /> ❑State Owned."DeLeri be Use CSht Number ❑Village of <br /> (Town oT r3r :S1w <br /> III.Type of Permit: (Check only one box online A. Complete line B If applicable) - • <br /> 4` NrNew System ❑Replacement System ❑TreatmentAlaiding Tank Replacement Only ❑Other Modification to existing System(explain) <br /> -1 List Previous Permit Number and Dale Issued <br /> fl. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New , <br /> Before Expiration Owner <br /> W.Type of POWT5_Systenr/ComponenUDevieer (Check all that apply) -------------- <br /> gNon-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound 24 in.ofsuitabte soil 0 Mound C 24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) _ <br /> V.Disperaal/Trentmont Arca Information: -- _ __-- - ------ ----- <br /> Design Flow(gpd) Design Soil Application Ratc(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation e <br /> (,O . / /s o /.5'-:? .� 9v. --- 9 , S" <br /> VI,Tank Into Capacity in Total 11 of Manufacturer <br /> Gallons Gallons Units <br /> o �� o t y <br /> "Mix Tanks exisrinaTanks n g 1 s 3 <br /> • c.w uts m w5 w <br /> �ar Holding Tank - S 6 /2y t Z_ _ P0.a.p u__ <br /> as <br /> riaawt w <br /> VII.Responsibility Statement-I,the undersigned.assume responsibility for installation iif the POWYS shown on the attached plans, <br /> Plumber's Name(Print) Plumber's Signature IIMPRS Number Business Phone Number <br /> dew t- , Mew n tell— ._ , *}c— ) 1 e . /so S' G op- ?3)-g/e 3 <br /> Plumber's Address(Street.City,State,Zip Code) — - _ <br /> Co S 13 C(4 C 9 W c...-,l t rcA._. , 4J:_ ')S i _ u <br /> VIII.Coon /Dc artmerrt Use tint _ <br /> • pproved ❑Disapproved Permit Fee Dal issued lssuin/ ;� '�/� . <br /> T S <br /> ❑Owner Given Reason for Denial t _ <br /> IX-Conditions of Approval/Reasons for Disapproval . <br /> Attach to complete plaits for the eyelet]and submit to the County only on paper not Jae than i 1,2 t I I lodes In size ��� <br /> rt8-g-154, Ch K' Y7/04/ . <br /> SBD-6398(R-01/07)Valid thru 01/09 <br />