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oommefceml.gov Safety and Buildings Division County. <br /> 201 W.Washington Ave.,P.O.Box 7162 �"rn 2'k <br /> 1 Sco n� Madison,WI,53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(21 Wis.Adm.Code,submission ofAis fort to the appropriate governmental <br /> unit is requited prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS aro PmjoMAddress(if different than mailing address) <br /> submitted to the Depertmant of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law.s.15.04(1 m Stab. <br /> I. Application Information-Please Print All Information /231 C <br /> Property Owners Name Parcel# <br /> 13r�n+ SCHRo2L�22 Oz8-`41244 -03Zf)0 <br /> Property Owners Mailing Address �- Property Location <br /> 3 7 0 8 T 112 RFl 11. " Govt Lot <br /> City,State Zip <br /> Zip Code Phone Number y, /., Section 7.4 <br /> ��1' <br /> Mn _ S 07 (circle on <br /> II.Type of Buil mg(check all that apply) Lot# <br /> T YD N; R /e Eo WW <br /> I or 2 Family Dwelling-Number of Bedrooms 3 1 G(_ 3 Subdivision Name <br /> Block# C$. . <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number - ❑ Village of <br /> PZ.17 ZTownof 5Cot4- <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New Sstem <br /> System ❑Replacement System ❑Treatment/Holding Tank Replacement Only g Other Modification to Existing System(explain) <br /> Cora Hatt Nera)!13,e r,�fo <br /> B. ❑Permit Renewal 11 Permit Revision ❑ Change of Plumber ❑Peanut Transfer to New List Previous Permit Number and Dam Issued <br /> Befoie.Expbrtiota Ownerf0604 <br /> �HTtcl.r Or rnRI.MLWuc <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ❑Non-Pressurized In <br /> y--Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in of suitable soil <br /> ❑ IcrHolding Tank Other Dispersal Componept(explaln)30 4--,1Ief 70 C .❑PretreaniumilDevice(explain) <br /> V.Dis ersaliTreatment Arca Inform ttlon: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requited(sf) Dispersal Area Proposed is System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer' <br /> Gallons Gallons Unitsc <br /> Nmv TanksP.xisling Tarika W V -' u '- <br /> cC cg h in <br /> Septic or Holding Tank <br /> Dosing Chamber /0&0 /000 1 uJeijer <br /> OO (000 <br /> VII.Responsibility(�qr�Statement-1,the undtni ed,assume responsibl for installation of the POWTS shown on the attached plane. <br /> PI MOtll a'Cf ll' is & EXCAVATION P a ignaNre MP/ti Number Business Phone Number <br /> aaeis 79 <br /> PlumbWCJaFks7.bKMWpt, {a ode) <br /> v� <br /> VIII.Coun aattment se n <br /> ❑ Approved ❑Disapproved Permit Fee Date Issued ISS114 Agent Signature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attack to complete plana for the system and submit to the County only on paper not Ian than 8 in a 11 Inch.In wise <br /> SBD-6398(R.01/07)Valid tlru 01/09 ro,; <br />