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1 <br /> itif Commerce VEGIEliWIE <br /> MAY AY . afety uildings Division County <br /> 14� ' .V.1. n Ave.;P.O.Box 7162 h <br /> i s co n S i n Ma lison; WI 53707-7162 Sanitary Permit Number(to b-efilled in by Co.) <br /> Department of CommbtutpUblic Health MDC 511 �-7 5 <br /> Sahita1 I GTI 1 {Itl i la�_OII 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 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(1)(m),Stats. <br /> I. Application Information—Please Print All Information Su m e <br /> Property Owner's Name Parcel 4 <br /> S i'e phan4' 1 CowaiL 0706 -10!- Soo <br /> 1 Property O er's Mailing Address Property Location <br /> Li <br /> SU q1 C0 0 n /d Govt.Lot <br /> City,State Zip Code Phone Number A'w v. N£ t/,; Section /0 <br /> elac k Earth 14 L1 53S 15 circle one) <br /> II.Type of Building(check all that apply) Lot T 7 N; R Co E or W <br /> ® I 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 <br /> CSM Number ❑ Village of <br /> /1 3y`/ IR Town of UtoerrteJn / <br /> III.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System it)Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Change of List Preyious Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision U Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground NZ Ai-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> `lS(l 1 9 o `IOC Q3,Of <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units c(5 11 i New Tanks 1 Existing Tanks o o c) J r <br /> a o to y i.7) i_ U <br /> L <br /> Septic or Holding Tank /00 I I /0 00 / /1MP a .e. ( ► <br /> Dosin¢Chamber 6 0 0 I /60 I �! ct f ,34 <br /> VII.Responsibility Statement-I,the undersigned,assu '• • 'onsibili%•for in lation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb- , . NIP/FRS Number Business Phone Number <br /> Siev«t (' cos bt l 02...2-760 `� cod'- y�'{- ry77( <br /> Plumber's Address(Street,City,State, .Code) �� <br /> vin.county/Department Use Only <br /> ?Approved ❑Disapproved Permit Fee Date Issued lssuina Age..i• t. e <br /> $ 7e3'-- 5l-7/0g <br /> ❑Owner Given Reason for Denial 1----- <br /> IX.Conditions o Approval/Reasons for Disa proval <br /> 5 c-- leA.A.,, h4--v-Li--S 1--- 4-c- te,o--ri,...-e..3_ <br /> a. s - C c/ 1 <br /> Attach to complete plans for the system and submit to the County only on paper DOt less than 8 112 o 11 inches in site <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />