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�"s4yi County <br /> 1 j Safety and Buildings Division 8�1rrite It- <br /> 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> S <br /> ;1t`Ps Madison,WI 53707-7162 <br /> ss89� w <br /> Sanitary Permit Application State Tran ctionNumber <br /> � <br /> 1 JJ <br /> In accordance with SPS 383.2 1(2),Wis-Adm.Code,submission of this form to the appropriate governmental unit p <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 A 5'8¢` <br /> purposes in accordance with the Privacy Law,s. 15.04(1 ynno-Stars. �7 <br /> L Application Information-Please Print All Information Gf/• /3L.S•S L/C /7Cp <br /> Property Owner's Name / ,,,� Parcel# 67C/b A'39V4,-47S.. <br /> m-r 13o,PrGff J��bz � 06 -003' Odd600 <br /> Property Owner's ailing Address - Property Location <br /> /5/!4 Go0,4e,C1, A, Govt Lot 3 <br /> City,State Zip Code Phone Number 3 <br /> Section 1 <br /> .��• Np w ( Al SS103- (circle one) <br /> T 3� R�E <br /> 11.Type of Building(check all that apply) Lot N, oro <br /> ry l or 2 Family Dwelling-Number of Bedrooms 3 �� Subdivision Name L <br /> Block# /OI C,N <br /> 0 Public/Commercial-Describe Use <br /> City of <br /> El State Owned-Describe Use CSM Number El Village of <br /> �rTowuof /llftn 0 h <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) -3_3a —O d <br /> A <br /> ❑ New System I Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com onent/Device: (Check all that apply) <br /> Q(Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 inof suitable soil 0 Mound<24 inof suitable soil <br /> 0 Holding Tank 0 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 list) Dispersal Area Proposed(st) System Elevation <br /> tiro . S 1 9o0 900 90. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> u _ tq <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> Vll.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's"Signature NIP/MPRS Number Business Phone Number <br /> A"/G/C filo IC)h <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 7760 Al • 3S d Vi e_6_4-1e,- ws J�_Ct85'7 <br /> VI L Countv/De artment Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued$ V Issuin Signature <br /> 0 Owner Given Reason for Denial ..�J�J-0 1r0 /V6U..CO� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans par the system and submit to the County only on paper not less than 8 1rz x 11 inches in size <br /> SBD-6398(R. 11/11) <br />