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.,5 County <br /> Safety and Buildings Division u,✓nretl' <br /> r N201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> i asp �j Madison,WI 53707-7162 <br /> SS 1 z F7 3 <br /> Sanitary Permit Application State Trans Ion Na bet <br /> In accordance with SPS 383 21(2),W is.Adm.Code,submission of this form to the appropriate governmental unit t..ifJeNG IG, I S� <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. /2�n /� d 25t r� <br /> I. Application Information—Please Print All Information G �(-�'^ U I <br /> Property Owner's Name Parcel#07-OJ 8- OS'— <br /> von 0 3 06- Dos-&1looa (o26-z4W-02-9ru) <br /> Property Owner's Mailing Address Property Location <br /> A7d. CO A C Govt.Lot 3 Z�f kJ A 1;6YA <br /> City,State Zip Code Phone Number —'A.N, Section 13 <br /> -S BOr/C <br /> (circle one#- Gf/T S"�80 / T <br /> IL Type of Building(check all that apply) Lot 4 �/� N, R /�' E o <br /> IN I or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> El State Owned—Describe Use CSM Number El Village of <br /> Town of 5C04` <br /> III.Type of Permit: (Checkonly one box online A. Complete line B if applicable) <br /> A. 11 New System < Replacement System TreamenHoldmS Tank Replacement Only Other Modifcation 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 Svstem/Com onent/Device: Check all that apply) <br /> QfNon-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(at) Dispersal Area Proposed(sf) System Elevation <br /> j5c" . 5 900 `boa s�sa <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units $ <br /> New Tanks Existing Tanks u c - n <br /> dU .n y n k. 0 i <br /> Septic or Holding Tank /BOO /00Q <br /> Dosing Chamber 600 B� <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 /> /Z/c% //a/o/C/ns {� a1�S8a / 7iS--�di-`/iS7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J 776 e W, y 3�rfT/126s"1+ lnr S"i/ T733 <br /> VIII.Countv/De artment Use Only <br /> II <br /> IJ Approved ❑ Disapproved Permit Fee Date Issued <br /> '/ Issuing A at S' nature <br /> El Owner Given Reason for Denial $ 7/'z1Ay �/2 <br /> I%.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 8112 x It inches in size <br /> SBD-6398(R. I1/11) <br />