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Safety and Buildings Division County <br /> a 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be fill d in by Co.) <br /> Madison,WI 53707-7162 Q <br /> ° sJos 3 / <br /> Sanitary Permit Application State IrarraannsacttionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (.may V ws <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 /> u oses in accordance with the PrivacyLaw,s. 15.04 1 m,Stats. l ` ,33 Ke 5 S k (-Q <br /> I. Application Information—Please Print All Information r <br /> Property Owner's Name '�11 Parcel# <br /> C ur n S ('�� ` 137 -oze-a-46-14-o2-4F aZ-odcv( <br /> Property Owner's Mailing Address Property Location <br /> 3 a <br /> L1)q:AJ <br /> e t3� srza+�tJ,a <br /> City,)ade Zip Code Phone Number AS/ 3S•� ��Q� Jrc '/., %a, Section�SO f9 ! �//,� �(cucle one <br /> TI.Type of uildin check all that a I Lot# T—�N; R�E or ✓ <br /> YP 8( PP Y) <br /> %-Or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use _ <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> XTown of .SGO <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 06ew System ys 11 Replacement System ❑Treatment/Holding Tank Replacement Only 13 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 POWTS S stem/Com onent/Device: Check all that apply) <br /> gNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in,of suitable 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(SO Dispersal Area Proposed(st) System Elevation <br /> 300 , -? Ya `/So 6, 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks w c u G <br /> ,ter c U iin rn ii. C7 G <br /> Septic or Holdier+enlc <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,(be undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 100 4 <br /> a <br /> Plumb Address(Street,City,State,Zip Code) <br /> ' 0XS1y <br /> VIII Count /De artment Use Out <br /> Approved [I Disapproved Permit FCC Date Issued issuing a ignature <br /> ❑Owner Given Reason for Denial 3z5�h� jo Au5 ,zol e- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 trz x 11 inches in size <br /> S13D-6398(R. 11/I1) <br />