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c enmerce.wLgoy Safety and Buildings Division County <br /> .ter <br /> 201 W.Washington Ave_,P.O.Box.7162 � ,, ��,J �- ,J,41.._ <br /> scons n Madison,WI 53707-7162 Sanity Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83/1(2),Wis.Adm.Code,submission of this form to the appropriate governmental /I -t"b r) -90?t t <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owed POWTS arc 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(1)(m).Stats. ` <br /> I. Application Information-Please Print All Information U(�t3`l,.-2s�[1 <br /> off- -Q(1:,t4S-- b <br /> Property Owner's Name Parcel# <br /> VOA 1 tit r F' --- :. _ '7 <br /> Property Owner's Owner's Mailing Address Property Location <br /> 6 b(-4{ q Govt. o <br /> City,State < t{ Zip Code Phone Number <br /> y (.l=-�1. . )4) /., Section-4 up t -- L 1 ,,,.+ 5/6 e i3 L., „-icircJt.gne) <br /> Type of Building(check all that ap•$i)" • `'* Lot 11 T ti N; R ! l�dr�y <br /> +--. amt y s" ' g-Number of Bedr.. . ,4" Subdivision Name <br /> 4 ,�, <br /> d <br /> •emu . s �l�.rd" "- � <br /> - lock# ❑City of <br /> 1 ❑ ::• ed-Describe ,se E.-kJ tf/"Ile ' CSM Number ❑Village of ..__ <br /> ' <br /> `1:-c� r ❑Town off'-' - ✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber , ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I Owner t :,j ,-j <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) 7:. y '' �`}7/ C. <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Moundd?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)�_.__. <br /> V.Dispersalrreatment Area Information: "kl 6.t-eIci`� <br /> Design Flow(gpd) Design Soil Application Rate( f) Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info - Capacity in Total 4 of Manufacturer <br /> ) Gallons Gallons Units a b _° <br /> y 4 New Tanks Existing Tanks o , Y a <br /> Septic or Holding Tank P I �j ,' ) L_.""!'^. `").- 4/` pc. , <br /> Dosing Chamber ✓ T '•'D <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P1 ber's Name(Print) Plu 's Signature y.., , MIGNIP C-Number Business Phone Number bee> r( .94(4.,Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use On , <br /> roved 0 Disapproved erntit Fee �„'- D. sued Issuin lgent Sign"u <br /> ❑Owner Given Reason for Denial • -„� <br /> IX.Conditions of Appr_oval/Reasons for Disapproval.. - ,q,, <br /> ,= `T4:a_T Er, r-'1 r • "~ is -r <br /> itCyL€..0 ti .S MEIN.. '' ,,•:c Cie.-1 4 � 'yr APR 2 5 Lill <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 i/2 x 11 inches in s,z <br /> 74' ?'a <br />