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<br /> -----
<br /> County:, --
<br /> i'V.XT',,:• 'fn . Industry Services Division litxrotlf
<br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.)
<br /> Ir. 1/4.,,,',40'.• 5) P.O. Box 7162 5AN1-22 -2210 t.d.acig2is/
<br /> Madison, WI 53707-7162
<br /> C-S-i- 22.-113
<br /> Sanitary Permit Application State Transaction Number
<br /> In accordance with SPS 383.21(2),Wis.Adna.Code,submission of this form to the appropriate governmental unit
<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 30.31—.--
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats.
<br /> 5 p-eo 1-ei''
<br /> I. Application Information-Please Print All Information I i/'
<br /> Property Owner's Name Parcel#
<br /> oi_oz) -W2-'41...075- /3-.—71(7 4
<br /> CIL ic y 0 A W50 VI
<br /> Property Owner's Mailing Address Property Location
<br /> 7 0 Fl /.57T,"IN it tV• Govt.Lot
<br /> City,State Zip Code Phone Number
<br /> IA,
<br /> Y4, Section -2
<br /> 17 r I 4,i,- 416 MAI 575-37) T N; R )7(circle one)„,
<br /> 4/0 / EorV
<br /> II.Type of Building(check all that apply) Lot#
<br /> I • •X 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name)
<br /> Ca.v ft t4.;44-. -1-0 ; 1.6,- Block#
<br /> •
<br /> 0 Public/Commercial-Describe Use
<br /> 0 City of
<br /> CSM Number n Village of
<br /> 0 State Owned-Describe Use
<br /> pkTown of 5ccrel-
<br /> III.Type of Permit: (Check Only one box on line A. Complete line B if applicable)
<br /> A. -jar
<br /> New System 0 Replacement System El Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> List Previous Permit Number and Date Issued
<br /> B. El Permit Renewal 0 Permit Revision 0 Chancre of Plumber 0 Permit Transfer to New
<br /> 9
<br /> Before Expiration "' Owner
<br /> IV.Type of POWTS:System/Component/Device: (Check all that apply)
<br /> WNO-n.VetUrifed in-Ground 0 Pressurized In-Ground 9 At:Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil
<br /> f.: :-.-A,'•"-':,
<br /> 0',ftoldiiiiTank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> .V. DisOeUal/Treatment Area Information:
<br /> DesietriT16*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation
<br /> /c5-° )ii-- ,
<br /> VI.Tank Info Capacity in Total #of - Manufacturer d.) ,,
<br /> Gallons Gallons Units r-. -0 .9
<br /> c.)
<br /> a) 0 d.,
<br /> (.., ._. -1
<br /> New Tanks Existing Tanks 4-9 0 ' 1 rP..— —&c) u] .
<br /> a.
<br /> Septic or Holding Tank _5-L/0 -q o / ,Trit,7(7,4-0,i-t, >
<br /> Dosing Chamber
<br /> VII.Responsibility Statement- I,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 /> RI 6/6 6 k 1 1-, s /a4--7-, /4/91,4- —1//5-7
<br /> Plumber's Address tStreet,City,State,Zip Code)
<br /> )776o g-y 31- Az .r/r, &1.7- 3-6/g5-3
<br /> VIII.County/Department Use Only
<br /> Pennit Fee,,,,40 Date Issued u. g A ent Signar/e i
<br /> Approved 0 Disapproved
<br /> ,‘
<br /> 0 Owner Given Reason for Denial $11 -5 9/16/gd . .',-,",,,i; 9 [ y E --- 1
<br /> ,_.,
<br /> IX.Conditions of Approval/Re sons r Disapproval
<br /> flee+. %IL . 47)01:,ci
<br /> SEP - 7 2022 j
<br /> ec7.
<br /> Attach to complete plans for the system and submit to the County only on paper not less than Lxiidyr.[§311,!
<br /> a ftces Department r
<br /> SBD-6393 (R0313)
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