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<44*s�Yty'ti Coun <br /> />; ,, - Safety and Buildings Division ���t r rile <br /> 116. 0 P r� 201 W. Washington Ave., P.O. Box 7162 Sanitary'Permit Number(to be tilled in by Co.) <br /> Madison,WI 53707-7162 <br /> I S .f ' F1 <br /> A 5588 77 lJ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 353.21(2),W is.Adm.Code,submission of this form to the appropriate governmental unit I 1 � ' <br /> is required prior to obtaining a sanitary permit Note-Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1 HmL Stats. <br /> 1. Application Information-Please Print.all Information Osd <br /> Property Owner's Name Parcel# <br /> �7 �a 43sga� C>7-0 <br /> i< L^VI✓I /.J err di�lA00 <br /> Property Owner's Mailing Address Property Location <br /> 9 89 C Rd M Govt Lot I <br /> City,State Zip Code Phone Number Z, A. Section 'A(p <br /> r0.nIt-C& 'r— T 3e N: R (circl�_e one) <br /> 11.Type of Building(check all that apply) Lot# <br /> ® I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> CSM Number ❑ Village of <br /> El State Owned—Describe Use <br /> `/ (� <br /> V • 111 1Q. a3� Town of CV60 oe /Z/,v-eV <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 0YA­,9"�;()(, --� <br /> A_ ❑ New System ❑ Replacement System El Tank Replacemen[OnlY �O[her Modification to Existing System(explain) <br /> en 1A ^0f.n / -/-0 A 3 /� <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 PONNTS System/Component/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 9 Mound>24 inofsuitable soil ❑ Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dis ersalffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> So 4 o qS-0 `fs-o `7r .17 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> n <br /> V <br /> New Tanks Existing Tanks � o _ — s <br /> Septic or Holding Tank <br /> Dosing Chambcr �p(((/ d <br /> Vll.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POxW'TS shown on the attached plans. <br /> Plumber's Name(Print) Plumbers Signature MP/MPRS Number Business Phone Number <br /> le 16 /70 /cfnf (/r-�yr.�• �P /� dd-f�S/ 7(S-Fill 6 - <br /> Plumber's Address(Stree 1,City,State,Zip Code) <br /> 770 el N _ 3s—w�4-rSvgs ? <br /> VIII.County/De artment Use Onlv <br /> V/ Permit Fee Dare Issued Alssuin � umature <br /> Il Approved ❑ Disapproved f /�)z <br /> ❑Owner Given Reason for Denial $375'x^-� 3 tAW <br /> It.Conditions of Approval/Reasons for Disapproval <br /> rSeGor%56rua�fmr of MUw,Q ox1 vcry< aF ave, increase <br /> p3 l3e.0 STzeG <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 UI a 11 inches in size <br /> SBD-6398(R. I1/1I) <br />