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3oteaarrtyr� <br /> Safety and Buildings Division Countyy 1,N e— <br /> q 7Z74- <br /> 201 W.Washington Ave., P.O. Box 7162 <br /> Madison,WI 53707-7162 sanit Permit Number(to be filled in by Co.) ( � � <br /> �P <br /> t1 <br /> �4g'rtm"` 5588 3 0 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit .Z13 0/O 8 <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 1 m,Stats. T <br /> I. Application Information-PleasePrintAllInformation 27/47 Tom STw4g RD <br /> Property Owner's Name Parcel# O O/ -i7• 9- .0 + <br /> C Ar/4 GJ rr,e i 1 ��#35�7q oS- sow - 0.77000 <br /> Property Owner's Mailing Address y/ Property Location <br /> /` 2_ G N/' ( Govt.Lot ,Z--3 <br /> City,State Zip Code Phone Number q/y ''/a, Section 3 <br /> .S'�// 7 Ys-�3,v j3Y3 T �/ N. RSL(circle or <br /> II.Type of Building(check all that apply) Lot# <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms ( Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use 1/ <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑Village of ---- <br /> V,Zpsy 1Townof p E i7o� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. 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 p-LU `><a,t Q-17-10 <br /> IV.Tvpe of POWTS S stem/Com onent/Device: Check all that a 1 <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade J9Mound>24 in,of suitable soil ❑Mound<24 in.of suitable sail <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(so System Elevation <br /> sa 7So Iso s'7 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o u <br /> New Tanks Existing Tanks c B `� u <br /> a U in � rn ii C7 G <br /> Septic or HoldingT4Tk <br /> Dosing Chamber �0 O DOJ <br /> VII.Responsibility Statement- t,the 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 /> GJ.4�L ��o/ G��.� zz769 3`i9-J-z86 <br /> Plumber's Address(Street,City,StatefZip Code) <br /> VIII Count /De srtrnentUseOnl <br /> Approved ❑Disapproved Permit Fee D e Issued Issuin Signature <br /> $ 2 <br /> ❑ Owner Given Reason for Denial 3 75 �% <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Tilts Sanlfdry Pe✓mtt S✓lxrcedc5 S.R 54-04,2), For a +ten+ o�51y» w+ r 1"U. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IR a 11 Inches in size <br /> SBD-6398(R, 11/11) <br />