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w M / <br /> commerce.i el v nXety Po "'dings Division County <br /> 1 A �20��VWW, Poi Ave.,P.O.Box 7162 'i8��•',`r_""1.' <br /> ti§con Madi on, 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> bepeartmeret d P a Health MDC 51 7 970 <br /> 0 <br /> San '1t'' •-.1 • 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.15.0451 Xm),Stats. �� , n }•-r�t <br /> I. Application Information—Please Print All Information O -k) t i <br /> Property Owner's Name LL Parcel# <br /> M Z% J ( Ivy <br /> Property Owner's Mailing Address Property Location <br /> k 2-(ca ~ Govt.Lot <br /> City,State Zip Code Phone Number Sr.( V4.s'hq '/., Sectio 2C <br /> (circle one) <br /> M aru b't� W 53-1(9 T -7 N; R S E or•W <br /> IL Type of Building(check all that apply) Lot# <br /> tl1 Subdivision Name <br /> �or2 Family Dwelling—Number of Bedrooms, �l <br /> Blpck#. k4VAA AsW _ <br /> ❑Public/Commercial—Describe Use ❑City of• <br /> CSM Number ❑ illage of <br /> ❑State Owned—Describe Use VTown of • sl GiiktA(t, <br /> ' <br /> III.Typ 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 ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV/Type of POWTS System/Component/Device: (Check all that apply) <br /> 'UrNon-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 <br /> (POZ) •1 1506 !57 3- <br /> . VI.Tank Info Capacity in Total II of Manufacturer ea <br /> Gallons Gallons Units a e j o <br /> New Tanks Existing Tanks o 0 8 , l; ° `N° <br /> A.v in en U.0 o. <br /> Septic or Holding Tank t2:, _ 12 el,_ 1 MeA DE, ■e <br /> Dosing Chamber �. (e5:7 1 _ . <br /> • <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/MPRS Number Business Phone Number <br /> Pyrptii,v,/ j . Ma-t k_. --AL- W ") / 22°16.- 851' 103 <br /> Plumber's Address(Street,sty,State,Zip Code) / <br /> best'3 C;?M c INa,t,,a Aux, J o 53 --7 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuin Si <br /> roved ❑Disapproved 3 3 /2"��] <br /> pp ❑Owner Given Reason for Denial S ' 51510 g <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> -a <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ills 11 inches in size <br /> • <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />