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Mar. 12. 2009 9: 00Av1 No. 0086 P. 1 <br /> cotllmlrcQ.Wl.gOV Safety and Buildings Division —County _ �� <br /> 201 W.Washington Ave.,P.O.Box 7162 •w‘C <br /> dS C sin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) • <br /> epartment o!Ootnmeroa 5/ go33 • <br /> '; State3ransactianTturilbcr <br /> Sanitary Permit Application <br /> In accordance with s.Comm.8331(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 POWI"S 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 Privaoy Law,3.15,91(1/011).Slats. �� ` i '� _ <br /> I. A .licationInformation-Please Print All Information ,G <br /> Property Owner's Name 1 Parcel 9 <br /> H.�n r \\ �, tc,\1 t al Gr.�:z _0% b(0�. 9 oc�1—c� <br /> Property Owner's ailing Address - Property Locati. <br /> l-‘ (01 C\ Q_ 1\C) csovt,tat ` <br /> City,State Zip Code Phone Number $(,v y, f J E %,Se on„ <br /> y (cirri one) <br /> ()�VhG. �Q T N; R �� (1:1. <br /> II.Type of Building(check all that apply) Lot <br /> Subdivision Name <br /> 04 or 2 family Dwelling-Number of Bedroom n <br /> 0 Public/Commercial--Describe Use r. -- ❑City of <br /> • <br /> CSM Number - ❑Village of <br /> [)State Owned-Describe Uso li v�k <br /> t.Tovm of 1 C tti <br /> G. • <br /> - 37.6, .Me'\QS a i■■,.e. . <br /> Iii.Type of Permit: (Check only one box on One A. Complete line B if applicable) T <br /> A- ( New System ❑Replacement System [I Treatrnent/HoldingTank Replacement Only ❑Other Modification to Usting System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal ❑Permit Revision 0 Change of Plumber ❑Permit Transfer to New <br /> Before kxpiration Owner _ <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) <br /> ❑Non-Pressurized In-Ground Q Pressurized In-Ground ':- At-Grade ❑Mound>24 in_ofsuitablc soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) , "— <br /> V.Dispersal/Treatment Area Information: - - <br /> - <br /> Design Flow(gpd) Design Soil Application Rale(gpdsf) Dispersal Area Required(SO Dispersal Arca Proposed(sf) System Elevation <br /> L-1 S vv a (.. 75 0 7 S 0 5e)c a'\- -V e.. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a E t j 3 h <br /> New Tanks heisting Tsnks <br /> AA 1 n:U vi y w 0 n. <br /> SeptisorftoldiagTtwk �dDb 'QVV ,/U1ea(^l'. , `'< ._ -. <br /> DosiagChamber to50 (,Sb_. 1 _ s - W. <br /> Vii.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plaos. <br /> Plumber's Name(Print) Plumber's Signature 4P/MPRS Number Business Phone Number <br /> h1ire... !\Aare.\nlz • .....A----e. G`> r a.)_-t) 1,1 (AA, 131= Sto'3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> _,� tAvct,.„ c, .e e. LOY ,,3 S G` <br /> VIII.County/De artmcnt Ilse Only ' <br /> permit Fee Date Issued! Issuing Agent n� <br /> "'Approved ❑Disapproved '80.62. '— 2`510 <br /> n Owner Given Reason for Denial ti7f / -• <br /> IX.Conditions,of Approval/Reasons for Disapproval <br /> l <br /> • Attach to complett plans for the System and subudr to the Couury only on paper not less than 8 taxi'inches to size•'”J —..--— <br /> Ck4- 41? to <br /> Sf3D-6398(R.01/07)Valid thin 01/09 <br />