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-2,,, I comme _ <br /> , _. . . ri m t.gov i Sa e�Buildings Division I Coun <br /> h' g o <br /> . i • 201 W. Was gton Ave.,P.O.Box 7162 Pt <br /> ISCO i jf P 3 0 2O Ma WI s„o7— 162 <br /> Sant ry Permit Number(to be filled in by Co.) <br /> Departments t • coerce _I / 3 <br /> Stanit• , bl^•l"• State Transaction Number <br /> implication <br /> In accordance with s.Comm. : . , , •t .I•.••! u = of this fcrrn to the appropriate governmental <br /> j 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(I)(m),Stats. <br /> I. Application Information—Please Print All Information � '�” <br /> Prope Owner's Name 1 Parcel 4 <br /> Prope Owner's Mailing Address /� Property Location <br /> ''5 7 t UU,/f /i(cP Govt.,Dt <br /> City,State <br /> ( � ,.� Zip Code � Phone Number <br /> t 10� (�/.� � C ��c A sG✓`/•� Section Z Y <br /> ,S,?' (circle one <br /> H. e of Building(check all that apply) Lot T Ni R- <br /> aI or 2 Family Dwelling—Number of Bedrooms ( ( Subdivision Name <br /> � I <br /> j <br /> Block= __ <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> G State Owned—Describe Use CSM Number a Village of <br /> own of ,1`74/..44"1 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> I ❑ New System enlacement System 1 ❑ TreatmenuHoiding Tank Replacement Only i '! Other Modification to Existing System(explaini <br /> I <br /> i <br /> B. 1 ❑ Permit Renewal ❑ Permit Revision I ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I Owner <br /> i <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> ; <ion-Pressurized En-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound<24 in of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) ' Design Soil Application Rate dst I Dispersal Area Required(st) I Dispersal Area Proposed(so System Elevation <br /> � g PP�� lgP ) <br /> ` I re `7 1 7)_ I 77c j /Y:5— <br /> VI.Tank Info l Capacity in Total . 4 of ' Manufacturer I I I <br /> 1 Gallons ) Gallons i Units r = I E e ( a ' <br /> New Tanks I Existing Tanks , I 2 3 t " 1 — '^ <br /> I I : I - J - .'d J �Z — <br /> Septic or iiouthuy.T.mtk i q <br /> Dosing Chamber ` <br /> . I j <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> I Plu 's Name(Print) f Plu.•.er's '.ignature I \IP'MPRS Number i Business Phone Number ; <br /> • umber's Address(Street,City,State,Zip Code) <br /> .-- : <br /> VIII.Countv/De•artment Use Only -`II„ <br /> Approved ❑ Disapproved <br /> Permit Fee I Date Issued Q� ' I . — .ignat j1'/ <br /> ❑Owner Given Reason for Denial '7�� � ,io/,/O V �t%t`�"1•+-,' . s • <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 3 1,2 s 11 inches in size <br /> be-811-8 I Cy,IL-- 145 2(0 3 <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> A <br />