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/1,.. ., <br /> / iiil...///' �1 H V <br /> • commerce.wi.gov CGD a tygj ,k3uilditgs , vision County <br /> 9 L ` 201 W. ashiit�n Ave O.Box 7162 Q+'� ''� <br /> It/1 sc a n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce } j C. i-1 1-, il C ?/j ' <br /> 5�. <br /> E t'r it +`. i th State Transaction Number <br /> Sanitary Verrini Ap-phcation <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),Slats. <br /> � <br /> I. Application Informati„�' - Information <br /> Property Owner's Name Parcel# liZ <br /> id 1 fr t 1 -- re ' 4,-Ci�t��r/' D707-3aa-94 Coo - 7 <br /> Property Owner's Mailing g Addres 01. `` I. ✓ k Zi u 1 (d_t'z) Property Location <br /> 7 9 tl” 3 <br /> /, <br /> /' o `T 1- c/ Govt.Lot lAj <br /> City,State a , , ' Zip Code Phone Number y., G' ) <br /> ikk7. h, Section J <br /> V�'Lf 4/L c5-3 S 6 a T .7 N R ,.,.i(circE. reSP <br /> II.Type of Building(check all that apply) Lot# t� <br /> 41-1--or 2 Family Dwelling-Number of Bedrooms Lir 0? Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use �t ` <br /> Town of C re's s, -1 Q)Mf <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System p y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ii Permit Renewal ❑Permit Revision ❑Change of Plumber ❑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 )(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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> (0 nC t C: /(S)C /66C) lido ` <br /> VI.Tank Info P h' <br /> Ca aci in I Total I #of Manufacturer <br /> Gallons Gallons Units I <br /> I <br /> o <br /> New Tanks Existing Tanks I L P V ° , <br /> v 0 ? „S, -- ' <br /> a.U y u_. <br /> C7 0. <br /> / // <br /> Septic or Holding Tank 1 �- .P 6, '/ -S ( �e&(: P V--Dosing Chamber �0 ge i) I I`c <br /> VII.Responsibility Statement- I,the undersigned • . •sponsib'lity for installation of the POWTS shown on the attached plans. I <br /> Plu s Name(Print) P ber i_ : e MP/MPRS Number Business Phone Number <br /> (_ � ocA_ (/�)b ,, % -_da '?669 62V)--gY%d7- /� <br /> Plumber's Address(Street,City,State,Zip CZe) <br /> 73 61 oaf- 1 ,., _ C G,./- 4- ---I a 4/ f A.1 3 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Si• . a <br /> /SApproved ❑Disapproved <br /> / $783 9/ z/aS ■❑ Owner Given Reason for Denial ti <br /> LX.Conditions of Approval/Reasons for Disapproval <br /> / <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> 1)8- a-7(03$' d,,le -- 't'-‘ Ro3 <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />