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commerce.wi.gov Safety and Buildings Division County � / <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> isco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application State lTransaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental ( �I <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.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name . I Parcel# <br /> Ef l G . - ( Stc 1,0 ru, / be107 /v4 3 056 0 <br /> Property Owner's Mailing A dress �J � � � �/J` �/� Property Locati <br /> -7 53 Mailing l (//v / r Govt.Lot <br /> Ci St to Z' Code Phone Number NW 'A, 51 y., Section /8 <br /> P 1 n, (Ail (circle ne) <br /> ��� T�N; R V•( (EylrW <br /> U.Type of Building(check all that apply) Lot# �Y <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# 13)a c K )�-t" <br /> C 11-e I el S / <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of_ <br /> Town of V ox (,rL/ <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 Other dification to Existing System(e lain) <br /> B. ❑Permit Renewal ❑Permit Revision CI Change of Plumber CI Permit Transfer to New <br /> 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 ❑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 /> .5-6) <br /> VI.Tank Info Capacity Ca aci in Total #of Manufacturer <br /> o <br /> Gallons Gallons Units .0 22 r$°o 9. <br /> ' <br /> New Tanks Existing Tanks c " 1 % <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume resp/for in tallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber'Oi afur MP/MPRS `Nu ber^ Business Phone Number <br /> ,4 Giro I1 d Ib 20 .3 605 6y3-2 391 <br /> Plumber's Address(Scree City,S te,Zip Code) ( �� <br /> g s� 11 ,--1. r614-17(-4- v k / w S -7 8 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Age cure <br /> proved ❑Owner Give $ 4-S-1 <br /> / / /`,�o�k ' <br /> ❑Owner Given Reason for Denial �Z`r �� <br /> IX.Co ditions of Approval/Reasons for Disapproval �/ <br /> 4�iNNEerri,v 7 . .■•'frfete4 l►'.fr S rf,e/v1 3642 . .4ftoPre dwNcS /1s r <br /> Ree,ep pe-60 , e-S7,,e/Crrd ode Le st wv/vg rar-l1 liWeed irs , 3 ..?fryp <br /> 5'tedisri7" e 7 • y ref pc T/4tr, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1 ,Ehe E I V ED <br /> AUG 21 2017 <br /> _ <br /> SBD-6398(R.02/09)Valid thru 02/11 `CANED Public Health MDC <br /> Environmental Health <br />