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CORiff erce.Mli.gOv Safety and Buildings Division County/� <br /> 201 W.Washington Ave.,P.O.Box 7162 ,()44 r'� <br /> triepearboarst sco n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> of �5440 21 <br /> Sanitary Permit Application State TryagaACt on N/umb7er <br /> Adm.In accordance with a.Comm.83.21(2),Wis.AdCode,submission of this form to the appropriate governmental 193 / (5 <br /> unit is required prior to obtaining a sanitary permit. Nate: Application forma for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary n / 7 G sof <br /> proposes in accordance with the Priv law,s. 15.0 1 m Stats. p( (L <br /> L Application Information—Please Print Ali Information >f--"-3 � <br /> Property Owner's Name Parcel# <br /> i �elty OS Monson <br /> PropertyOwner's Mailing Address r // ?3ti�r/ Property <br /> Location <br /> of ES-9i('0 O S / I "Oc� <br /> WE85tEi <br /> ee.etm <br /> City, <br /> /State <br /> / Zip Code q Phone Number y5�yy Section <br /> (N !O C{� li✓.. �y �/ s(CJ(J �� (� crmle one <br /> II�a.r Type of Building(check all that apply) Lot# T_��N; R� E <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Bloch# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of -- <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> {1Town of G/ /tJ G p /0 <br /> IM Type of permit: (Check only one bo:on line A. Complete line B if applicable) ja _ <br /> A' ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. LI Permit Renewal ❑ Permit Revision ❑ Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POINTS System/Component/Device: Check all that �r1 <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ Atlaade K Mound>24 int of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersalffreatinent Area Information: <br /> DesignFlow(gpd) Dear Soil Application Rate(gpdat) Dispersal Area Required(st) Dispersal Area Proposed(at) <br /> System Elevation <br /> �{So y5 o yl r <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks F,xiating Tanks <br /> septi`a'Istatag T°ar © G O dd0 <br /> Dosing chamber 0 <br /> VII.Responsibility Statement-1,the anderdgned,ase®e respomibnity for Costa ladon of the POWTS shown on the attached plans. <br /> Plumber's Name( 41 <br /> Plumber's Signal= MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code)c- <br /> XGX-S-/Se �/1/` <�- 4✓ GUS S`F� �2 <br /> VIIL CountylDepartanent Use Only <br /> Approved ❑ Disapproved Permit Fee <br /> 7 �i Date Issued Taming Ag gnature <br /> ❑ <br /> Owner Given Reason /for Denial § l 5 j /1 Ak�&)f <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plana for the system and submit to the County only on paper net less than 9 In s 11 Inches in else <br />