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7 .ir X75R4 c,k_ to y a�0 4 <br /> .. <br /> . , <br /> commerce.wl Safety,j g ';_ilding, Division County <br /> JUL - 801ry as."� �.. Ave.,P.O.Box 7162 9 A'i E. <br /> tit SCO L� �•• 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> epartment of Commerce S!Sa S S <br /> Pubilc f jean a MD State Transaction Number <br /> Sanitary Ple m tAppTiicItiQn <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 0 0(24c.... .._ 0) <br /> purposes in accordance with the Privacy Law,s.15.04(lxm),Scats. Y <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 1-\OM.55 6:›(2- ooe Tg.«o PS i CsJ C. O4/ - 2 s )- - C3y -Oo <br /> Property Owner's Mailing Address Property Location <br /> 3 7 v\A Au-i 5 r . <br /> City,State Zip Code Phone Number /kW `/,, N e `h, section ac <br /> 'j'AuNTv A 0 D.72b bo ) 3I - ZlZ`i T g N, R fn E <br /> II.Type of Building(check all that apply) # <br /> ©'1 c 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Bloc (>2-r-E co p-1 › ,,1,-+'`LY ' • <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use ®Town of (?;`-1 2-te---"E- <br /> IIL Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> `;" ©'IJ System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑ 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 /> 8'N-on-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑ Mound>24 is 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(at) Dispersal Area Proposed(at) System Elevation <br /> I, 00 a . y / son / 3-0., -7 3•/ ' <br /> VI.Tank Info Capacity in Total #of Manufacturer o = <br /> Gallons Gallons Units i c <br /> New Tanks Existing Tanks v o ^� C e m <br /> � �p� a U in n r� ii Z L7 0.. <br /> Septic ec#Ieldng Tank / 2 S() /2.V) Dk t vIA-e-P 7"y X <br /> Dosing Chamber 7 7) — 7 S� I ON C v�_ ._ / <br /> VII.Responsibility Statement-I,the undersigned, responsibility installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signer `/.v�yr�"'7'•�•`PRS Number Business Phone Number <br /> .)n✓io • 50Ale: ,/,..5"? 2 (acs:- tLt-8 yoga <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z LZ ( (61 jf 44Cr tP A4 R� s'ot1 ti _, .f 3 7r3 <br /> VIII County/Departoknt Use Only 1 <br /> Permit Fee Date Issued Issuing end Signature <br /> 33--Approved ❑Disapproved 7 Q 5'- O a <br /> ❑ Owner Given Reason for Denial S`337 co CJ <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 8 1/2 z 11 inches in Size <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />