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. . />-". . <br /> +i <br /> -Dib# ar)Itio U1* atnr1 <br /> commerce.wi.gov <br /> it <br /> 1 SCO Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 (z/�lt_ <br /> fl Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 578 032 <br /> Sanitary Permit Application State Transaction Number <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.13.04(1)(m),Stats. � l/// <br /> I. Application . orm ' rint All Information ( 1 N8 r"(/ <br /> Property Owner'.Name . Parcel <br /> • t• , E. e°/' 6767. / -Yd Ve - 6 <br /> Property Owner's Z._/0 M-. .a Address Property Location <br /> 5 /C t Govt Lot <br /> City,State Zip Code Phone Number <br /> / A/ /<, /'2` /<, Section o)o) <br /> j1 /4/074 z,„') (circle one) <br /> /v T `t N., R -7 E or Zd;- <br /> II.Type of Building(check all that ap. Lot 4 <br /> l,a 1 or 2 Family Dwelling—Number of B•drooms 3 J Subdivision Name <br /> Block <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> • CSM Number ❑Village of <br /> ❑State Owned—Describe Use /j . <br /> js� j`� ) Mown of ( e b S J PL r di S <br /> III.Type of Permit: (Check only one box on line A. Complete line B(if applicable) �C <br /> ' <br /> A. <br /> eNkNew System ❑Replacement System ❑Treatment/Holding Yoldmg Tank Replacement Only ""'k E i yst <br /> lz nj <br /> • <br /> B. ❑Permit Renewal ❑Permit Revision D. Change of Plumber L Permit Transfer to New <br /> JUN �000 <br /> Before Expiration Ow Previous Permit Number and Datt-.mub: <br /> ner 'I O <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 4 <br /> ❑Non-Pressurized In-Ground ❑Pressurized hi-Groin-id ❑At-Grade ❑Mound>24 in.of suitable soi c(MosPI1t3iCiiL it#rhltMp0 <br /> Environmental Health <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment a.,i,.(�_,pluu, <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(f) System Elevation <br /> 4/ 6-) / • o Y!r yr?). q ' 3 <br /> VI.Tank Info Capacity in Total I T of Manufacturer <br /> G-all_ons Gallons Units I 2 S <br /> l U <br /> New Tm s; Existing Teals , J r <br /> / U .171 Z V rn CU <br /> Septic or i oldine Tani: I J 0 Sr I I C5,1-Z / cc t,e - <br /> Dome Chamber ((- t G) I 66.1) <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber' Tce e(Print) Plumbe s u e / 1v1P/M RS Number Business Phone Number <br /> � a� '�j�' ` __ ,47// 7e,e5;1 t.,,- 'Y l- rY?7( <br /> tfle Plumber's Address(St eet,City,State,Zip Code) <br /> VIII.County/Department Use Only I <br /> Permit Fee I Date Issued Issuing Agent Signature i <br /> Approved ❑ Disapproved t Q Q <br /> ❑ Owner Given Reason for Denial S I 7 U3. 6/aco/o[� / j <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1 <br /> i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 51/2 a 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />