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�1 Lv <br /> v commerce. d uildin s Division County <br /> �' g ty-PA AJC <br /> 201 W.W•• -�fin Ave.,P.O.Box 7162 <br /> fISCOfl 'y ,_�i JUN 2 6 2008Mad *,t Wi 53707-7162 tAJ{\ ,'-Sanitary Permit Number(to be filled in by Co.) <br /> Department of Co a —� io l� O'Y 578 QS/ <br /> Sanita ' ation-)Q a-f) <br /> State Transacti Number <br /> � ,�._ �.5;: • /Cligg0I <br /> In accordance with s.Comm 83.21 Q),Wis.��f��yls�his form o the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application Corms 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(I)(m),Stats. nL/,I/'I� /� <br /> I. Application Information-Please Print All Information ( (•� /y ``O. <br /> Property Owner's Name Parcel# <br /> R tC,14 SC/10014 r2& <br /> Property Owner's Mailing Address <br /> /f rd t- Property Location <br /> ss <br /> i i �d` C" Govt.Lot <br /> City,State Zip Code Phone Number , , <br /> [/ / /4Jj J v, /, Section /� <br /> S ty CC'r �� �3 S�3 C C 1 y I ('�/c/ . (circl `ne) <br /> / 13 T g N; R r r W <br /> A.Type of Building(check all that apply) Lot# <br /> Al or 2 Family Dwelling-Number of Bedrooms / / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> CI State Owned-Describe Use CSM Number ❑Village of <br /> h�'9 Town of /1/17-c;yl'� � <br /> f 1 <br /> 4 <br /> • <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' <br /> Ai'New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal II Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground RAt-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 /> 6'6 ' 5 /flame /200 Pi.frr t , 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> I Gallons Gallons Units o g <br /> u New Tanks Existing Tanks o o u a E <br /> m <br /> w U i N n <br /> i% 0 G1. <br /> Septic or 4el&ittg T nk / ZS) /� /)2�jr / (/t l <br /> Dosing Chamber n/T / 7yt�/6 �/ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum r' Signature ��_ MP/MPRS Number Business Phone Number <br /> (.�2 r rt #a t-a, a i'_Coil /�'�" — v )-)i‘/ ce16.—75:3 - -,.y <br /> Plumber's Address(Street,City,State,Zip Code) �j <br /> �( y Ste, -e e .-�� ,{✓ F6e-fi f e-ii e,L 1,1 i 5.J.J d 7 <br /> VIII.County/Department Use OAT <br /> y.Approved ❑Disapproved Permit Fee Date Issue Issuing Issuing Agegentt'Siignature <br /> ❑Owner Given Reason for Denial $793•— 7/71 i Y v <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> /— <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1a s 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />