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rix.c-:'rte County <br /> ',XSafety and Buildings Division <br /> s D S 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> PS• � Madison,WI 53707-7162 /41 <br /> s <br /> Sanitary Permit Application State Transaction Nu <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit C D IJA, e✓t'E t't/ <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(i)(m),Stats. '/- / n <br /> I. A //4 <br /> Application Information-Please Print All Information / ! tOr- <br /> Property Owner's Name Parcel# <br /> IE/04Nt &1b a 1/1- 17-! 03-ado-dwevo <br /> Property Owner' bailfi/innAgg AddressL' Property Location <br /> falls -J Govt Lot <br /> City,State Zip Code Phone Number , t/ , Z' <br /> / v/I�/A Cly, �j�p �j �/,. Alf /., section-2 <br /> /, -AV-16#2- T�N: R I&circlEorev <br /> 11.Type of Building(check all that apply) 7 Lot# <br /> Pr1 or 2 Family Dwelling-Number of Bedrooms ` 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> /�7o V n/��/ Town of �Ly i <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) �6 <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <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 P06VTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> i$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(sf) Dispersal Area Proposed Is System Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ;= <br /> E!U rn w Gn i*. V R. <br /> Septic or Holding Tank Zoo v <br /> Dosing Chamber h �J <br /> VIT.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plrioy"O �&Lnde_,- <br /> s Name(Print) PI ignature /,- MPiMPRS Number Business Phone Number <br /> = /�� >xo z, <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> Z 7ZZU if, <br /> VIII.County/Department Use Only <br /> Approved I ❑Disapproved Permit Fee D Date Issued Issuing Agent S gna <br /> ❑Owner Given Reason for Denial <br /> 376. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D ECEOVE nn <br /> Attach to complete plans for the system and submit to the County only an paper not less than a Itz s 11 inc e OCT A O 2016 <br /> O16 <br /> SBD-6398(R. I Ill l) 13URNETT-COUNTY <br /> ZONING <br />