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t <br /> •iti <br /> commerce wl.gov ! ' Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 IDA Ft i- <br /> I n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Deparhnerd of Commerce 5/ 80/ 8 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission t°ra?t o v <br /> unit is required prior to obtaining a sanitary permit. Note: Appli f � �5 Project Address(if different than mailing address) - <br /> submitted to the Department of Commerce. Personal information trovide may be used for seconliasy 1-7 SQ rytwt V S R <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stats. <br /> L Application Information-Please Print All Information — '' 2,— <br /> Property Owner's Name JUN C Parcel# <br /> W I L.L.I ANA/1 W CA 2 ov G-4 oR I( - 1 Z2 - cl_.rd'J <br /> Property Owner's Mailing Address Public Health MD -Property Location <br /> 1.4.4 T n oSi-4/41-t om _r. Environmental Health <br /> City,State Zip Code Phone Number 5 y,,,,LAA J 1/4, Section I Z <br /> v.r-) p t2Pr i R-l i (......1 -3 3-.9 f6(4 Y Z S— 8 t)y T / N; R ll E <br /> �-IL Type of Building(check all that apply) , f Lot# <br /> t_Y1 or 2 Family Dwelling-Number of Bedrooms l/.�' 2- Subdivision Name . <br /> Block# '�— <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of 2^ <br /> 7 P2 <br /> ogg ®Townof LSTvL <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber El 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 /> LYNon-Press uized 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(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units i § c�b <br /> New Tanks Existing Tanks `i: c m `B' m a <br /> 42 Z. A i co w O P, <br /> Tank 121 sro s9 / CREST X <br /> Dosing Chamber / 73-0 / „ g, X <br /> VII.Responsibility Statement-I,the undersigned,assume 'batty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI Si: I. MP Number Business Phone Number <br /> JOHN E.RASMUSSEN -7e1 223-732 (608)635-4305 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> , ` • <br /> ARLINGTON HARDWARE CO.,INC.,303 MAIN STREET,ARLINGTON,WI 53911 <br /> VI 1L County/Department Use Only <br /> pproved ❑Disapproved Permit Fee 00 Date • ed _ . Signature / <br /> S <br /> �� ti <br /> ❑Owner Given Reason for Denial 3.3 i 1/ �� �`/ MitlIM_ <br /> IX.Conditions of Approval/Reasons for Disapproval ,00."-- k <br /> i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inches in size <br /> SBD-6398(R.01/07)Valid thlu 01/09 <br />