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. . 2):, E ( il ' l I 1 .,0ii8 -,APR 92 \ <br /> tiicommetrce.W Safety and Buildtigs Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 .1-..,c...-, <br /> seo n s n ailC Health toiarison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Co rce Env. unchenial Health 51791/5— <br /> Sanitary Permit Application JStatc Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental r f � ? <br /> unit is required prior to obtaining a sanitary permit. Notc: Application forms for state-owned POWTS arc Project Address(if different thanmailing 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),Slats. S" .4_rs (/0.l le-t/ PO,k r-✓o�7 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name 9 f-j4Jaier s1^,9.4)„,E c, ,63 .0�,v Pared# . <br /> z _,/ 04"/ - 0 Su.R-1.2/ - 8S35--6 <br /> Property Owner's Mailing Address ' ^ Property Location <br /> 2 o r 1 I.. j.A c�.�t-,)j' Cam---r <br /> Govt.Lot <br /> City,State Zip Code Phone Number /V c..-' y. V is y., Section 12- • <br /> (circle one) <br /> bre U- CA�r . S �]S T S N; R 0 EorW • <br /> II.Type of Building(check all that apply) r Lot#X I or 2 Family Dwelling-Number of Bedrooms J Subdivision Name <br /> Block tl <br /> ❑Public/Commercial-Describe Usc — ❑City of <br /> ❑State Owned-Describe Usc CSM Number ❑Village of <br /> / a 3s/ >31 Town of _...144 0 f" k-rc5C- <br /> . t1I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. XNew System y ❑ Replacement System ❑TreatmenUl{olding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to Ncw List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Devicc: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade Mound>24 in.ofsuitablc 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> 75 o /. o 75 c. 7S.,A._ Se/- c,:t S,j-L <br /> VI.Tank Info Capacity in Total b of Manufacturer <br /> Gallons Gallons Units 1, ,, o 0 <br /> Ncw Tanks Existing Tanks o 2 Z u <br /> o.U in . vs w 0 P. <br /> Septic•s•NoWiag Tank ,S'-C) — /6 S6 2 .. A-J c? ,:� ->C <br /> Dosing Chamber / 9 G c> go iJ / ii.. k <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature I /M('RS Number Business Phone Number <br /> /9v-7C-- f ) L . /-!eft 1 IJ _.--3,-_____Q_ t - - c?- 0)‘__C- 6ok-d'3 i— /c 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6e i3 C7i-) ' /..r' w ,-, ((LA._ Co L . 5-35 l ? <br /> IS-Approved County/Department Use Only <br /> xJ�lpproved ❑Disapproved <br /> Permit Frey Date Issued Issuin Agc Sign re �,� <br /> ❑Owner Given Reason for Denial S / �� 471-151-a8-a8 (. L��a1-'` 11,--- ------ <br /> IX.Conditions of Approval/Re3,sons for Disapproval <br /> s (°w /t l-/y,'4/-e/7(A(7 // <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a I I Inches In size <br /> D 7 7' 3hK-361533 <br /> SBD-6398(R.01/07)Valid thus 09 <br />