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• commerce.w;_gov Safety and Buildings Division County 1 <br /> Gi <br /> 201 W.Washington Ave.,P.O.Box 7162 1 <br /> sc+o n S i n Madison,WI 53707-1162 -' (J 162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 1 5D7 <br /> Sanitary Permit Application . t 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 s;e 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)(m)y Stats. nn <br /> I. Applicatjon Information-Please Print All Information rQ(-(S f�� <br /> Prope Owner's Na a Parcel# <br /> O".0,,,,1 i) (3 <br /> -45`1 /2 O5 3 y 2Zoe) • <br /> Property Owner's Mailing Address Property Location <br /> 20 .)_ S C'7 114 Govt.Lot <br /> City Zip Code Phone Number n i� , <br /> �J�b(.,� t. 1--f 5 2 � r V�= SIjJ A Section )� <br /> �/V 5 I ne <br /> D.Type of Building(check all that appl Lot# T I N; R jam!W <br /> t'1 or 2 Family Dwelling-Number of Bed s 3 <br /> c2R Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> / -7 3 Town of j J �L <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. -, New System` y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ ether Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber 0 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.of suitable soil Iound<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 Spit A lication Rate(gpdsf) Dispersal A Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> L 5 6C! ( ( 45 - y5S _ 10 ,. <br /> VI.Tank Info Capacity in Total #of Manufacturer - <br /> Gallons Gallons Units v - -0 <br /> U <br /> New Tanks Existing Tanks A u — y <br /> a. U vy rn i.5 P. <br /> Septic or Holding Tank GO 3 <br /> Dosing Chamber jj..�� e-5-e) -- - - - 1 <br /> LJ - - ` F v TI... <br /> VII.Responsibility Stateme't-I,the undersigned,assum-rest rnsibility for installation of the POWTo :wn on the attached plans. <br /> P ber's Name(Print) Plumber's Si r ' <br /> rj '� P: PRS Number Business Phone Number <br /> V �:,,� r fr�91q' Z 2(>YYz. L0j -Ys i 7 <br /> P mbe Address(, et,City, tate,iip ..e ' <br /> tO L-17 tli T- 5 3 i 2_,5-VIII_County/Departm nt Use Only <br /> Approved ❑Disapproved Permit Fee cc) Date Issued Issuin• gent Signat ' �� <br /> I ❑Owner Given Reason for Denial .i I 1 11 O . <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> . . . , . r _ r' _. iC,, <br /> . t ■HAT <br /> ...... <br /> Attach to complete plans for the�system <br /> ��and-submit to the County only on paper not less than-S 1/Z'z"I J inches in'size ' ' � �' - "-7✓C <br /> D I °��6� I L ' r '—' r� i t n <br /> ��535 L'i h V ADDITIONS <br /> SBD-6398(R.01/07)Vakiljthrn 01/09 to C f -1 i <br />