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commerce oy c i y S ry uildings Division County <br /> L5 h 2 W was on Ave.,P.O.Box 7162 n�`t <br /> , 'It.i c co fl Mac i I D3707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of C erce 518 D r7 <br /> San try Iermi A pp 2008 ton Sate Transaction Number <br /> In accordance with s.Comm.83.21(2):Vis.Adm.Code,submission of th,3 form to the appropriate governmental <br /> unit is required prior to obtaining a sanitaiPingttitHdtflit IOlaation for for state-owned POWFS are Project Address(if different than mailing address) <br /> submitted to the Department of Comnler99v gReli,retairei*hhj•ou_rovile may be used for secondary <br /> purposes in accordance with the Pnvacy Law,s. ID.U4(1)(m),Stats. _ <br /> I. Application Information–Please Print All Information Ib SG.� 6 0 <br /> Property Owner's Name Parcel 4 <br /> Property Owner's Mailing Address kJC Property Location <br /> 9\ J Y eat- l.-1 x.40 ✓ Govt Lot <br /> City,SAtaie Zip Die Phone Number Section q <br /> alcieli <br /> V clrcie one) <br /> II.Type of Building(check all that apply) Lot 4 T N; R E or W 1 or 2 Family Dwelling–Number of Bedrooms S, 3 Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial–Describe Use "— <br /> ❑City of <br /> ❑State Owned–Describe Use �n <br /> CSM Number ❑Village of <br /> p.Townof !,[ t, 11e/a9 <br /> /i 05)3 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. i <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> a. <br /> ❑ Chan List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑Permit Revision ge of Plumber U Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> g Non-Pressurized Ln-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 /> 7.50 , `1 I V 1 j c- 6 $ 7, s . <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units J i o <br /> New TL Existing Tanks •r = o <br /> Septic or Holding Tank I its c L I 1 ko SO I I I /21 P a_r0 e <br /> Dooms Ch_ber I <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 Sienature MP/MvMPRS Number Business Phone Number <br /> K 0 iir -/, /71r('e,- I(,0_.4. i17— azy!`/ 16,0tr- . 7Y1- 7( <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 73c ? -Do,/- 1 ; r,_ lI 61 � '- 5 3 c)- f <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Pen?it Foe Date Is–sued lssuin_Agent '_° z <br /> / ID Owner Given Reason for Denial 5300.— 7/1 l/08 <br /> LX.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!'a II inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />