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.i., --t____ <br /> ErE11Vi CAe re 11079Zy 06 n ?.5-.zs <br /> * cOmme1"Ce.W r "e ,. •llildings Division County <br /> A 1 201 W.Was f ,i Ave.,P.O.Box 7162 D,�1t,1 E-,,rr�' I sCO f — i m tk�.. 1 3 2C? i i�j, l 53707 7162 Sanitary Permit Number(to be filled in by Co:)D of - ., --' l:� r 5 J 7 9 S a _ <br /> Sanita 6 l !i e 1 1 i , tion State Transaction Number <br /> In accordance with s.Comm-83.21(2),Wis.ittlph;p.pdepsubtnidsioliedribis forms,the appropriate governmental <br /> - <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 OLD STpp.1 f_ R,D_ <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel ft <br /> -3__2E. n 1 4 t 1)a-.P 6.PP L °S2(os1 - 21Y - qQs?) - <br /> Property Owner's Mailing Address Property Location <br /> Sb LA2 uv- LN <br /> City,State Zip Code Phone Number .5E y,, 9 E 1/4, Section _21 <br /> 5'r o u 6-WTI) t-$ 1 c.-11 S 3 s'9• `6 040 V?3 --Ls-7'7 T .� N; R /n E <br /> II.Type of Building(check all that apply) (� Lot# <br /> o I r 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of _ <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> /'O.S 7J . ®Town of R rLA-'D <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- [I-g;; System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ 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 /> { 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(st) Dispersal Area Proposed(st) System Elevation 40.2 <br /> 4'CO , - <br /> Of ! STD ° /'IJL 41•l 'A 42-a; 9z-q• <br /> VL Tank Info Capacity in Total #of Manufacturer M <br /> Gallons Gallons Units o o 0 •O Gallons <br /> New Tanks Existing Tanks o m V i % <br /> ./14-(..47V1 w �'�f <br /> a. C.) co m a. 0 P. <br /> • <br /> Septic or-Adding Tank 1'3 0 O /3 o' 1 0 AP-'�/ x • <br /> Dosing Chamber 7S ) 7Sz) / t t r1 <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 /> r <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL County/Department Use Only I / <br /> 'Approved ❑Disapproved Permit Fee deb Date Issued o Ls + � i` <br /> ❑Owner Given Reason for Denial S �/�3/Q 8 `/IP ,t#�..i, ,5 ,(re <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 z 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />