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• - - - QElLilViE - . <br /> 7� 1 @ D ,2 4,3L/7 <br /> commerceiM. v MAY 7 ety rrt ]dings Division County <br /> 201 W.Wasl-ingtor Ave.,P.O.Box 7162 _ <br /> MndilDn,W, 53707-7162 — <br /> S C n s i n Public Health MDC Sanitary Permit Number(to be filled in by Co) <br /> • Department of comrnercEnviror mental Health 517q-16 <br /> Sanitary Permit Application sWteTransa"`°nNumber <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,5. I5.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name. Parcel# <br /> e <br /> Property Owner's Mailing Aress • Property Location <br /> 317 5 Q ,^• 1 r r Govt.Lot <br /> City,State e Zip Code Phone Number ,, A, <br /> II/kJ . }� n�.. /., ,Y E /., Section <br /> s 3 t" Iji_ 5 3-7 U 0Q� 719 ° Z3 C (cir .grte) <br /> II.Type of Building(check all that apply) Lot# T 7 N; R 1 b ( E q�W <br /> gI or 2 Family Dwelling—Number of Bedrooms 1 Subdivision Name ��' <br /> Block 0 <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> ( � l Town of(Alt 1110 5 <br /> ) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. X,ciew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber ❑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 /> Non Pressurized In Ground 0 Pressurized In Ground ❑At Grade 0 Mound>24 is of suitable soil ❑Mound<24 in.of suitable soil <br /> r❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVTreatment Area Information: <br /> Design_Flow(gpd) •Design Soil Ap lication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) Stem E anon <br /> S G.3-9ioa <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 0 4 0 <br /> R u <br /> New Tanks Existing Tanks ° 2 R ,a <br /> 0 <br /> /� o.O rn m us u..3 a. <br /> Septic or Holding Tank I Z t(, 1-O'(, ) i n 2 cl j4 I - <br /> Dosing Chamber j) _ .l6W- t ti/ <br /> Le 1,(j I <br /> VII.Responsibility Statement-1,the undersigned,assume ponsibility for installation of the POW . o , on the attached plans. <br /> PI ber's Name(Print) // Plumber's n t e MP 'RS Number Business Phone Number <br /> • r, 4r. ,t,�r t li C_ _ le 1(If Z `,2"CLZi v-s'1 <br /> P m 's Address(Stye City,St�,Zip Code) <br /> 0 (..t f Z 6_4, 6__ ice.%Z s 5) <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing nt Signature <br /> S 337.00 , -8-0 8 , C73 _.- <br /> Cl Owner Given Reason for Denial <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2:I I inches in size <br /> • <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />