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`wcMyy County l <br /> Safety and Buildings Division of <br /> D 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ZSPS el, Madison,WI 53707-7162 f ��(o <br /> Sanitary Permit Application Stale Transaction Number <br /> In accordance with SPS 383.21(2),Wis.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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Slats. p <br /> 1. Application Information—Please Print All Information .66s1 6,,)C V r P,, <br /> Property Owner's Name Parcel# <br /> Trent& 14zek o��rc z o-t 21-5- 07-08s-017eoo <br /> Property Owner's Mailing Address Property Location <br /> 160 �� e- Govt.Lot `�7 <br /> City,State Zip Code Phone Number ,. Z <br /> f y]�� �ys��- Section <br /> /V ew/&� /e/'�f 57��./ 6sI-Y57-9eYz (circle on <br /> II.Type of Building(check all that apply) Lot# T�o N; R E o <br /> XI or 2 Family Dwelling-Number of Bedrooms 6 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> v /O A?/J U Town of (/M'0*-J <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) /� <br /> ` , DrNew System ❑Replacement System Treatment/Holding Holding Tank Replacement Only Other Modification to ExistingSystem(explain) <br /> ❑Change of PlumberList Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal El Permit Revision g [6Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent(Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 19 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c v <br /> New Tanks Existing Tanks <br /> O y <br /> a. U m 2 m iC V a <br /> Septic or Hatding Tank Z570 <br /> ZSIV� 1 w <br /> Dosing Chamber —/—� <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown an the attached plans. <br /> Plroo, <br /> s Name Plumb ignstore MPrMPRS Number Business Phone Number <br /> nCce� /av' 051?5 7/5-566 -02oz <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2 ?ZZv �arq,r'�n/ �(e�sls^ 1..J <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing AgenZure <br /> ylli �j O / <br /> ❑Owner Given Reason for Denial $ J��0 3 �"�!R <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not Ins than 8 In s l l fiches in size <br /> SBD-6398(R. 11/11) <br />