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County <br /> Safety and Buildings Division USN <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filial in by Co.) <br /> p;`5PS ;f Madison,WI 53707-7162 -gySgq <br /> Sanitary Permit Application State Transaction Ntnnber <br /> in accordance with SPS 383.21(2).Nis.Adm.Code,submission of this form to the appropriate govemmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different dom mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with time Privacy Law,s.15.04(1)(m),Stars. <br /> 1. Application Information—Please Print All Information <br /> Property Onmces NameDe Parcel# <br /> 7 -2 �2&Z 01-�D-o/3oav <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,Stare Zip Code PhoneNtrmber �Y., NL(/ y, Section l+ <br /> 6 sYd /s--*3-z etroleor TN; R�B <br /> 11.Type of Buildin (check all that apply) *3 Lot f <br /> Subdivision Name <br /> 1 or 2 Family Dwelling—Number of Bedrooms <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> Town of Lft1L//ir+#'S4W <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System TIReptacement System ❑TreatmentlHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to Nets List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1V.Type of POWTS S stem/Com nent/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.ofsuitable soil ❑Mound<24 in.ofsuitablesoil <br /> ❑ 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> ys o 6 H 6 '7 9+� <br /> Vt.Tank Info Capacity in Total #of Manufacturer 8 <br /> Gallons Gallons Units s 2 3 <br /> New Tanks Existing Tanks ii ;.+ C u .e c <br /> e.U 'af m in L• O G <br /> Septic or Holding Tank- 000 ` w <br /> Dosing Chamber VVVV <br /> VII.Responsibility Statement—1,the undersigned,assume responsibility,for installation of the POWTS shown on the attached plans <br /> Plum s Name(Print) / Plumber's Si MPiMPRS Number Business Phone Number <br /> 05� DG4M'�tC� 8S7`t5 ?45-566-0 Z_ <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> 27Z90 w6451-15" L jr` .rJ,119F <br /> III.Coun /De artment Use Only <br /> Approved ❑Disapprove Permit Feed o O llama Issued Issuing Agent Sign <br /> ❑Owner Given Reason for Denial S 37S/ O 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to cmaptete plans rar the system and submit to the County onk on pat er not less than t n2 x 11 Inches to sue <br /> SBD-6398(R.I1111) <br />