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.4„,, q/s"0 g <br /> commerce.wi.gov iafety and Buildings Division County <br /> it <br /> 201 W.Washington Ave.,P.O.Box 7162 OLtat <br /> Q Sc O n Q] Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department o■f C■ommm■erce 5/ 7 9 6/3 <br /> State Transaction Number <br /> Sanitary Permit Application <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. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel/1 <br /> 0.4C— o(,1(-Z T2-641d-0 <br /> Property Owner's Mailing Address) Proper t/ i)-3 ty Location <br /> 2 .7 w {Y\c/in Si, <br /> o <br /> G t.co � <br /> City,State j Zip Code <br /> �' Phone Phone Number } Q` V,, t\)i.,13 y., Section 2.1 <br /> 5to V e a t/.( 5-3c. <br /> 3 D q tPo? ZoS` �l ssI (circle one) <br /> T (it N; R_ j),W <br /> H.Type o Building(check all that apply) `, Lot f1 <br /> #l'orZ Family Dwelling-Number of Bedrooms q Subdivision Name <br /> I Block y <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> / . -- <br /> t ' 3 `"R Town of et e SG;.nt S4 t<'t �s <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 dHoldin g Tank Replacement Only <br /> ❑ 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 /> 1 Before Expiration ' Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) Ij <br /> S.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 Applic lion Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed 1sf) System Elevation <br /> (PeO C -4 !SCC? 15Oo ,5.. .,e. ■G-t V`tcov'1 <br /> Vi.Tank Info Capacity in Total II of Manufacturer y <br /> Gallons Gallons Units E °a <br /> U <br /> New Tanks Existing Tanks . c .,2 p3 . `—° m <br /> _ w U co rn u- t_� W <br /> t Septic-.va,aa ank i �a t&-t 1( <br /> i'2 Sty/?S"a. ,Woo i 1)� rr N- <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plrimber's Signature MP/MPRS Number Business Phone Number <br /> S'3-a_vrz Tas n-tar - tC.v P:I,yr 'v <br /> Plumber's Address(Street,City,State,Zip Code) ," <br /> I <br /> 1U 84S"t�' l4 WI 0 1 V4'e Q-r ,on W-5-7* S3 S9 <br /> VIII.County/Department se Only <br /> Permit Fee Date I sued e nr, tt.igna .re �+ <br /> Approved ❑ Disapproved $ �l — 5 Jow .4AP A . �f'� 7 , <br /> ❑ Owner Given Reason for Denial ��/'f�// <br /> IX.Conditions of Approval/Reasons for Disapproval D S tC f 0 E II <br /> -, <br /> MAY 1 9 2008 <br /> Attach to complete plans for the system and submit to the County only nn paper not less than 8 it z 1 i in/hes in size <br /> - Public Health MDC <br /> Environmental Health <br /> SBD-6398 R.01/07)Valid thru 01/09 - <br />