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r IV <br /> 7.....4 <br /> P34k 13c.2.i. (11.4* 4a j1 1 L... . <br /> • commerce.wi.gov Safety and Buildings Division County I <br /> 201 W.Washington Ave.,P.O.Box 7162 f/Ci.it <br /> ti S CO n s 1 fl Madison.WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 578 05-0 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2);Wis.Adm.Code;submisn. .'this f' th . . <br /> unit is required prior to obtaining a sanitary permit. Note: , 4 :tior •i,fortta ilow dg WT• Proiket Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal informs e•�.0 provide may be used for se.. . <br /> .0 loses in accordance with the Privacy Law,s.l5.04(1)(m),Staa <br /> I. A..lication Information—Please Print All Informat 12111=IIIIMM71111111111 Sp,n e <br /> Property Owner's Name I I . ' V Parcel <br /> ✓r' <br /> I (C y 5C17 (,4.)e A 7't 6 7 O& - / I - - .S Cl?2 - 5 <br /> Property Owr1er's Mailing Address YUbfIC Heafttl MDC Property Location <br /> n/ Environmental Health _ <br /> 7'( I S 11lac-k $ 1 ue e ,/C G* Govt.Lot <br /> City;State Zip Code Phone Number .5 Gv %, /b.✓ '/; Section /f <br /> 17'e ec na Le)r 5-55-i 3 (circle one) <br /> II.Type of Building(check all that apply) Lot 4 T N; R g E or W <br /> Ei 1 or 2 Family Dwelling—Number of Bedrooms -� <br /> � Subdivision Name <br /> AZ <br /> Block= era+'rte V t S <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CS1v Number ❑Vi page of �7 p <br /> Town of /11 t ek CC l '" <br /> . <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. y <br /> ❑ New System t[7 Replacement System ❑Treatment/Holding Tank Replacement Only ID Other Modification to Existing System(explain) <br /> . 111 "` <br /> g <br /> List Previous Permit Number and Date Issued <br /> B• ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber El Permit Transfer to New <br /> Before Expiration Owner <br /> ■ <br /> IV.Type of POWTS System/Component/Device; (Check all that apply) <br /> R 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 q 2: C. <br /> 6b0 r 1 rsaS'5 7, PI /2oc7 qy, .3 . 43, 7 4' I <br /> VI.Tank Info I Capacity in Total 4 of Manufacturer ; __ I I <br /> Gallons I Gallons Units I I <br /> Net.Tanks Existing Tanks ` v i <br /> r <br /> c U rn y Cl) _ 'v <br /> Septic or Holding Tat I <br /> /P2-00 /POC ( I Meatiz PC I i <br /> Doing Chamber I ROC , ROO. I I I I 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 Signature MP/MFRS Number Business Phone Number <br /> Kfhn 6th /2I¢1p K ,.L,4,-; /7/2-`//Y A C C',f- ,Y)Y 7- o .7 7 1' <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 73(, e Vicar1 -, C. : I)63 Ai t Lk_) T =, 4 <br /> VIII.County/Department Use Only <br /> /Approved ❑ Disapproved Permit Fee 'D]ate Issued Issuing Age ign•„. e <br /> ❑ Owner Given Reason for Denial $331)' - � 1/7/08 �/ YY <br /> I.X.Conditions of Approval/Reasons or Disapproval <br /> t-^^-Gt' V"-s� W Co-d- ...- Cor-NA. /Gc-A-t-C <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81,2111 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />