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!a-'7`::aii\ - <br /> , ''``�� Industry Services Division County <br /> , 1400 E Washington Ave t�krr <br /> �y,`�Sp `1 P.O.Box 7162 <br /> ` S :S.' <br /> Sanitary Permit Number(to be filled in by Co.) <br /> 'f, �_ Madison,WI53707-7162 SA�1_,2,2 —` <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),1Vis.Adm.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 Services.Personal information you provide may be used for secondary 75 7. ,1 <br /> purposes in accordance with the Privacy Law,i 1 All Information <br /> Star on �/ Tl <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name <br /> Parcel <br /> avd Zwleh/ 07- ?itaig-. 1cies-001-0/ _ <br /> Property Owner's Mailing Address <br /> tltl �j Property Location <br /> f t73 " W Z/S f�`N Govt.Lot _ �95 <br /> City,State Zip Code Phone Number <br /> eve &'41 rL 39�( <br /> T ' Section 3 y <br /> it N; R ` circleE ono e)_+J <br /> II.T e of Building(check all that apply) Lot# �� <br /> EXor 2 Family Dwelling-Number of Bedrooms -z' 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> row n of 3'46 k <br /> vit P2 y <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System 0 Replacement System Ir Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Perntit Transfer to New <br /> Before Expiration Owner 21 026 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> CJ'Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) <br /> 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispeal Area Required(sf) Dispersalea Proposed(sf) System Elevation <br /> 300 VZ ( y g5 4, <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units = <br /> New Tanks Existing Tanks 2. u U <br /> a`.U in v in Li; D a <br /> Spttc or Holding Tank /1W/�` f <br /> �J 1 42k4� V <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Ptun cr's Name(Print) Plumb ignatu� MP/MPRS Number Business Phone Number <br /> to f4Adel �i�j l <br /> Plumber's Address(Street,City,State,Zip Code) �� / ���—S -OZpZ <br /> 6567 4v7ziAl z le i4I ( Je6A- Lb' 51/&9 3 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Age Signatur <br /> ,�Approvctl 0 Disapproved <br /> 0 Owner Given Reason for Denial ( S3 5 ,51512 J/2 <br /> IX.Conditions of Ap fIroval/Rea ns fqr Disapproval <br /> ('lei- 4 Sei-bccU(-5 4'i .3os <br /> ,375. �.. . <br /> y 2 I* <br /> Attach to complete plans for the system and submit to the County only on paper not less than 814 ; j es a sine <br /> Y \ <br /> I .i. y e <br /> SBD-6398(R.08/14) <br />