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2j2t,l ioJ Cr <br /> Check lb 332 6'5 D8T6 /aq, <br /> • commerce-wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave..P.O.Box 7162 Q Nye_ <br /> iSC o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co <br /> Department of Commerce 51 1 op <br /> Sanitary Permit Application State Transaction <br /> ,N/umber <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental j pttZ L /204v1 Number <br /> 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.15A4(1Xm),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> y ; Igo ■ Qr-k-h v P 05010318ogo 1 <br /> Property Ow s Mailing Address (� Property Location <br /> 110 O ` ' - C' ) �N I1J r. Govt.Lot <br /> City,State Zip Code Phone Number N E �; N E y, Section 3 <br /> v e o N 0. 53 3 « Cn�j (circle one) <br /> IL Type of Building}check all that apply) Lot# T Jr N; R 1 E or W <br /> E 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of p <br /> ®Town of Pa-iR.rn5- - <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System ®Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Ni Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaliTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3b ' <br /> i15 D r Mo 15(� /50 �4y�S <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .0 E i;•g o <br /> New Tanks Existing Tanks o 2 e. a : m <br /> rt 0 in V rn w O P.. <br /> Septic°rpleldii%Tank 1 0 O -- j1.000 I tbAZ-MA°v L/ <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Timothy J Jelle 227525 608-845-7466 <br /> Plumber's Address(Street,City,State.Zip Code) <br /> 501 Commerce Parkway Verona Wi 53593 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuin Agert ignatu <br /> %Approved ❑Disapproved co <br /> III Owner _?,210 owner Given Reason for Denial Hy—O 8 4' 74,14, -- <br /> • IX.Conditions of Approval/Reasons for Disapproval <br /> --j 4CiSVAC- eq W 7./,' Ir/l LG /Ave 7 L'E lQV frsf'? l(6 ' <br /> ivtiC--/•( Are,/ yo,I,rc (.r cpAlai-Le 60. EX(1 RFfi4F ' 476"-4-6e0 <br /> -1st ee w T.I,' /140r e- r P‘ <br /> Attach to complete plans for the system and submit to the County only paper not less than 8 . <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> PI ECEOWE ---) <br /> JAN 9 2008 , <br /> Public Health MDC <br /> Environmental Health <br />