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,•� . I'ounty <br /> � Safely and Buildings Division <br /> 201 W.Washington Ave., P.O.Box 7162 <br /> is/11�5+yt gni 91 Sanitary Permit Numberbo be Nrd in by Co.) S <br /> P � Madison,WI 53707-7162 1 \1 <br /> '/2/ <br /> Sanitary Permit Application SaacTT �9 N" h� <br /> In accoNarce with SPS 383.21(2),Wis.Adm.Coil,submission of this Soon to Ne appmpdate govemmental unit CiCas.eP(✓ &0',) <br /> is requild poorer obtaining a sanitary pmnit. Note:Application toner for stateownd POWTS art submitted to Project Addsess(if different than nailing adde,a) <br /> rhe Depanmeru of SafdY and Professional Swim. Pws infomauon You pmvide maybe uud for s=ndiry <br /> u m in accordance wilh the Privac Saw,s. 15. IMm,Sm¢. <br /> 1. Application s Information-PleasPrim All Information Z E 7 <br /> S_ <br /> PnOdy 0me's N <br /> Nr ame <br /> l <br /> e 7 o7 u12-2-'10-15-II-SIS-71/-otl§CCD <br /> 3 07-02- 2 •vo-IS- It 5 IS OIIF 0q 000 <br /> Piopeny Owner's Mailing Address Property location <br /> '7 s <br /> L t i l 1 Gov,Lot_ <br /> City,StateZip Cde Phone Number y,, R, Sectio <br /> L ; C 0 I Z L GZ (cimleon ) <br /> 11.Type of Building(check all that apply) Lmq T - �N; R�Ea,& <br /> N I or 2 Family Dwelling-Number of Bedmorm 7) G Subdivision Name <br /> ❑PubliGCommemial-Describe Use Black V 50' ,+ <br /> ❑Ciry of <br /> ❑Sure Owned-Ddcribc Uu CSM Number ❑mIv Village of <br /> 111.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. New SI. Replacement Sstm ❑Trestratern/Holding Tank Retalacernent Only Other Modification to Existing S Inn <br /> (explain) <br /> R. ❑ Permit Rmewal DO Permit Revision W�a List Previous Permit Number ad Dam Issued <br /> Change of Plumber ❑RTmilTmmfer to New (l <br /> Before E,sPimtiun Owner �Sd 92 Mq✓(; -I - � <br /> IV.Type of POWB S stem/Com onentlDevice: Check all that stop 1 <br /> m Nan-Prsssurird In-Ground ❑Parasudzd b-Good ❑ At{rade ❑Mwutl>_24 in..f mimble soil 0 Mood<24 in,of suitable it <br /> ❑ Hulding Tank ❑Wrr Dispe,al ComWiamt(exp1in) ❑Pmoccureu Dcrwe(explain) <br /> V.Dis rsaVlreatmant Area Information: <br /> Design Flow(gpit I Design Soil Application Ratc(gpdsf) lhvp. I A Ryui,d(sH Dista al AroaRopased(sf) Sys Elcvation, = <br /> 450 . 5 7, a5 %, 9 .50 �f5= <br /> VI.Tank Info Capacity in Total pot Manufacturer <br /> Galbm Cullom Uwa s $ <br /> Nev Ta F 'mv,TW.a w <br /> aU y2 H U < <br /> Sepic m Baaing Tani I.0 C2 C) <br /> rbsin,ChnmM <br /> VII.Responsibility Statement- [,the uodenignrl,aaume onpamibiliry for Installation of the POWTS thaw.no the imancmd pi... <br /> Plumber's Name(Prim) Plmnbtt's Si MP/MPRS Numbs Business Phone thunder <br /> v✓; e k C p M M;) p15-7 93 <br /> Plumber's Add cera(Strew,City,State,Zip Code) <br /> s W� S9�7 <br /> VILL Count /De artment Use Body <br /> Wr Approvd ❑ Disappmvd Permit Fa Datc Issued Issuing gtutu <br /> S .na� <br /> ❑Ownu Givrn Rmmnfar Denial �saJ 'r 2U <br /> IX�`.�1Coadhions of A1_pprovanRea,ma;for Dmple.sn.�l� flD ���� <br /> rypm: 7{lr5 �,A.I,e Relxa. s Q"L ncpljgtr {K- Awry 1ea+a '*A <br /> CD <br /> undo Sp s5B925 <br /> CG %0z) JUN 2 6 2013 <br /> Aaerh Io complete clam for rhe-prem a"d Sub rlt m On,Conroy only oo pe,r.ol len than!Inp j)Via,In stn <br /> ounrvM COUNTY <br /> ZONING <br /> SBD-6398(R- 11/1 1) <br />